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FORTY  YEARS 


IN    THE 


MEDICAL  PROFESSION 


FORTY  YEARS 


IN  THE 


MEDICAL  PROFESSION 


1858-1898 


BY 


JOHN  JANVIER  BLACK,  M.D. 

MEMBER   OF  THE  COLLEGE   OF   PHYSICIANS  OF   PHILADELPHIA;    MEMBER   OF   THE 
DELAWARE   STATE   MEDICAL  SOCIETY,    ETC. 


'yf  ?nan  is  as  old  as  his  arteries'' 


PHILADELPHIA 

J.  B.  LIPPINCOTT  COxMPANY 

1900 


Copyright,  1900, 

BY 

John  Janvier  Black. 


d-A^'^W^   ^^U6v*w^^> 


PRINTED    BY  J.   8.   LIPPINCOTT    COMPANY,    PHILADELPHIA,    U.S.A. 


PREFACE 

I  HAVE  given  forty  years  of  faithful  and  conscientious 
work  to  an  exacting  and  laborious  profession,  and  here  are 
the  notings  of  some  of  the  results.  I  trust  they  may  enable 
my  readers  now  and  again  to  while  away  a  leisure  hour. 
Call  them  what  you  will;  call  them,  if  you  choose,  the  mere 
flotsam  and  jetsam  which  have  rolled  in  upon  the  waves  of 
the  sea  of  my  personal  experience,  and  which  have  been  cor- 
ralled by  the  breakers  and  strewn,  figuratively,  upon  the 
shore,  in  the  following  pages. 

JOHN  JANVIER  BLACK. 

New  Castle,  Delaware,  December,  1899. 


CONTENTS 

CHAPTER    I. 


PACE 


Voyage  to  San  Francisco — The  Isthmus  of  Panama — The  Western 
Coast  of  Mexico — Arrival  at  San  Francisco — United  States 
Marine  Hospital,  San  Francisco — Diseases  among  the  Sailors — 
The  First  Japanese  Embassy  to  the  United  States — R.  H.  Dana, 
Jr. — San  Francisco  in  the  Early  Days — The  Medical  Profession 
— Duels — The  Climate — San  Francisco  in  1894 — John  China- 
man   13 

CHAPTER    II. 

University  of  Pennsylvania,  Medical  Department,  i860 — The  Build- 
ings and  Conveniences  for  Faculty  and  Students — The  Faculty — 
The  Lectures — The  Quiz  Classes  and  Students — University  Char- 
acters— Outside  Teaching — The  Course 32 

CHAPTER    III. 

The  Jefferson  Medical  College,  Philadelphia — The  Faculty — Joseph 
Pancoast  and  James  Syme — S.  D.  Gross — The  Tone  of  the  Pro- 
fession in  Philadelphia — Clinics — Hip-Joint  Cases — Clinical  Lec- 
turers in  Philadelphia — The  Atlees  and  other  Great  Men — Pro- 
fessional Methods — Trained  Nurses — The  Philadelphia  Hospital, 
Blockley,   in  the  Early   Sixties — Typhus   Fever 48 

CHAPTER    IV. 

Started  for  Liverpool  in  a  Sail-Ship — Tornado — Narrow  Escape  and 
Return  to  New  York — Better  Success  by  Steamer — Paris  in  1866 
— The  Hospitals — The  Doctors — Velpeau,  Jobert  de  Lamballe, 
Nelaton,  Ricord,  Sichel,  Charcot,  Trousseau,  Liebreich,  Pasteur, 
J.  Marion  Sims — Napoleon  III.  and  why  he  failed — Tone  of  the 
Profession  in  Paris — London — Sir  William  Ferguson.  Sir  Thomas 
Watson,  Sir  James  Paget,  and  Others — Edinburgh — Simpson  and 
Syme — Ether  and  Chloroform — Berlin — Von  Langenbeck — Fre- 
richs — Vienna — Clinical  Schools  and  Lectures — Billroth,  Skoda, 
Oppolzer,   Tiirk.  and  Others 67 

7 


CONTENTS 
CHAPTER   V. 

PAGE 

Returned  from  Europe  and  Settled  in  New  Castle,  Delaware — Its 
Peculiar  Freedom  from  Certain  Diseases — The  Medical  Profes- 
sion in  Delaware — Country  Doctors — A.  Conan  Doyle — Ian  Mac- 
laren — Bacteriology  Forty  Years  Ago — Pathogenic  and  Other 
Germs — Toxines — Immunitj' — Inflammation — Operations  Forty 
Years  Ago  and  their  Results — Asepsis — Antisepsis — Origin  of 
Life — Sir  Joseph  Lister — Obstetrics  and  Antisepsis — Hospital 
Gangrene — A  Strange  Coincidence — Surgery  away  from  the 
Centres — Disinfection — Necessity  of — Gonorrhoea — Bladder  Trou- 
bles— Syphilis — Eye  Troubles — Gynaecology — Proctor  Knott — Ap- 
pendicitis— Radical  Cure  of  Hernia — Intubation  and  Trache- 
otomy— Fractures  and  Dislocations — Instruments — Rontgen  Rays    87 

CHAPTER    VI. 

Post-Mortems,  etc.,  Forty  Years  Ago — Treatment  of  Pneumonia  Then 
and  Now — Heart-Troubles — Digitalis,  etc. — Auscultation  and  Per- 
cussion— Vivisection — Improvements  in  Pharmacy — Dangers  in 
Drugs — Sugar-Coated  and  Compressed  Literature — The  Blood — 
The  Trolley — The  Bicycle — Preventive  Medicine — Diagnosis — 
Wall  Diseases — Nitrification — Malthusian  Theory — Diphtheria — 
Croup — Sir  Morrell  Mackenzie — Tetanus — Immunity  as  to  the 
Sting  of  the  Honey-Bee 126 

CHAPTER   VI  L 

Nervous  Diseases  Forty  Years  Ago — Somnambulism — Hypnotism — 
Motor  Disorders  —  Lunacy  —  Delirium  Tremens  —  Epilepsy  — 
Chorea — Diseases  of  the  Cord  and  its  Membranes — Tetanus — 
Hydrophobia — Hysteria — Neurasthenia — Dr.  D.  D.  Richardson's 
Views  on  the  Treatment  and  the  Care  of  the  Insane — The  Feeble- 
Minded — Notes  by  Dr.  Martin  W.  Barr — The  Deaf  and  Dumb — 

Colonel  William  Boiling John  Brainwood — Thomas  Hopkins 

Gallaudet — Edward  Miner  Gallaudet — Hon.  Amos  Kendall — Dr. 
Crouter — Peet — Rogers — Gillett — Noyes — Fay — Manual  Method 
and  Speech — Swedish  Movements — The  Bath — Electricity — The 
Masseur  and  the  Masseuse — Hypnotic  Suggestion — The  Danger- 
ous Classes — The  Degenerates — How  shall  the  Problem  be  solved?  173 

CHAPTER   VII  L 

Ptomaines — Definition  of,  etc. — Composition  of,  etc. — Vegetable  Al- 
kaloids— Changed  Food  Supply — Canning,  etc. — Poisonous  Gases 
in  the  System — The  Different  Ptomaines — A  Growing  Evil — 
Fatigue  and  Ptomaine  Poisoning — Chronic  Ptomaine  Poisoning 

8 


CONTENTS 

I'AOK 

— Ice-Crcam  and  Crcam-PufF  Poisoning — Personal  Experience 
in  Ptomaine  Poisoning — Auto-intoxication  in  Disease — The  Re- 
flexes from  Ptomaine  Poisoning  and  Auto-intoxication — Patho- 
genic Poisons — The  Death  Struggle  and  Auto-intoxication   .    .    .   i88 


CHAPTER    IX. 

Diet  now  on  a  Scientific  Basis — Study  the  Individual — Idiosyncrasies 
—Teach  Diet  in  the  Schools— Diet  in  Youth  and  Old  Age— Carls- 
bad and  its  Doctors — Diet  and  the  Poor — Division  of  Foods — 
Animal  and  Vegetable  Foods — Tissue-Builders  and  Force-Pro- 
ducers— Uses  of  Food — Oxidation  and  Health — Water — Rations 
for  Individuals — Children  and  Protcids — Atwater  and  Woods 
on  Composition  of  Foods — All  about  Eggs — Fish  compared  with 
Beef,  etc. — White  Potatoes,  Spinach,  Asparagus,  etc. — Lead  Poi- 
soning— Coffee  and  Tea — Chocolate  and  Cocoa — Dietary  Studies 
among  the  Plain  People — The  Germans  and  German  Thrift — 
Study  of  a  Family  as  to  its  Diet,  Cost  of,  etc. — Diets  for  Cor- 
pulency and  Leanness — Systems  of  Diet — Banting  and  Others — 
Different  Kinds  of  Breads — Toast,  etc. — Kissingen  and  Vichy 
Remedy  for  Fatness — Food  consumed  per  Person  per  Year  in 
Different  Countries — Time  required  for  the  Digestion  of  Various 
Foods — Sterilizing  and  Pasteurizing  Milk — Infant-Feeding — Ar- 
tificial Infant  Foods— Diet  for  the  Old— Ward  McAllister— In- 
fantile Scurvy — Concerning  Milk — Tests  for  Milk — Regulating 
the  Milk  Trade— Graded  Milk I97 


CHAPTER    X. 

Origin  of  Alcohol,  Whiskey,  Brandy,  Port  Wine,  Sherry,  Champagne, 
Burgundy,  Claret,  Rhine  Wine,  Porter,  Ale,  Beer — Per  Cent,  of 
Alcohol  in  Each — Effect  of  Alcohol  on  the  System — Effect  of 
Alcohol  on  Bodily  Temperature — Alcohol  as  Food — System  con- 
sumes more  in  Disease  than  in  Health — Strength  of  Wines — 
Colors  of  Wines — National  Drinks — Methods  of  artificially  aging 
Whiskey,  etc. — Rum,  Gin,  Cordials,  Malt  Liquors — IMethod  of 
making,  etc. — Malt  Extracts — Wines — Grapes,  Varieties  of.  etc. 
— The  Wine-Taster — Peculiarities  of  Wines — Sherry,  Madeira, 
Port — Ward  McAllister — Burgundy,  Sauternes.  Hock,  Johannis- 
berg — Champagne  "  a  Drink  for  the  Gods,"  as  well  as  an  Inven- 
tion of  the  Devil — Vin  Brut,  Vin  Sec,  Vin  Tres  Sec,  Sparkling 
Moselle — German  and  Italian  Wines — American  Wines — Cali- 
fornia Wines — Care  in  prescribing  Alcoholics — Value  of  Fruit 
and  Nuts  as  Articles  of  Diet — Value  of  Fruit  as  Food  from  an 
Economic  Stand-Point — The  Lesion  in  Rheumatism — Is  Fruit 
Healthy  Diet? — The  Divisions  of  Fruits — Special  Fruit  Cures — 
The    Ripening    of    Fruit — The    Most    Digestible  .Fruits — Fruit 

9 


CONTENTS 

PAGE 

Syrups  and  Fruit  Juices — Canned  or  Tinned  Fruits  and  Vege- 
tables— Fruits  in  Colonial  Times — Fruit  in  Florida,  California, 
and  Australia — Medicinal  Properties  of  Fruits  and  Nuts — Why 
Leaves  change  Color — The  Apple — Varieties  of  Apples — Varieties 
of  Peaches — Varieties  of  Pears — Grapes — Apricots — The  Plum — 
East  India  Fruits — The  Mangosteen — The  Durian,  Pine-Apple, 
Banana,  Plantain,  Orange,  Shaddock,  Olives,  Lemons,  Mulberry, 
Melons — Partridge-Berry  and  Salicylic  Acid — The  Haw-Berry — 
Gooseberries,  Currants,  Cranberries,  Cherries,  the  Quince,  Black- 
berries, Raspberries,  Strawberries — Decay  of  Fruit — Mushrooms, 
Morels,  and  Truffles — Nuts — Chestnuts,  Peanuts,  Almonds,  Fil- 
berts, Pecans,  Shellbark  or  Shagbark,  Brazil  Nuts,  Chilean  Nuts, 
Betel  Nut,  Pistachio  Nut,  Kola  Nut,  Guarana,  Butternut,  Wal- 
nuts— Eucalyptus  Globulus 269 


CHAPTER   XL 

George  B.  Wood  and  S.  D.  Gross  on  Tubercle — Koch's  Discovery  of 
the  Bacillus  Tuberculosis — Present  Definition  of  Tubercle — 
Physical  Attributes  of  Tubercle — Tubercle  Bacillus  in  Man  and 
the  Lower  Animals — Pulmonary  Tuberculosis  in  Man — The 
Physician  and  Tuberculosis — Early  Diagnosis  Important — The 
Bacillus  and  Diagnosis — Case  of  Chronic  Interstitial  Pneumonia 
and  Tuberculocidin — Tuberculins  and  their  Therapeutic  Principles 
and  Uses — Toxines  and  Antitoxins — Koch's  Tuberculins  A,  O, 
and  R — Maragliano's  Serum — Virchow's  Objections  to  Koch's 
Tuberculin  A — Mulford's  Serum — The  Economics  of  Tuberculin 
— Tuberculous  Cattle  in  Europe  and  America — Necessity  for 
Action — Prevention  and  Treatment  of  Tuberculosis — Surgical 
Tuberculosis — Treatment  of  Haemoptysis — Murphy's  Method  of 
treating  Pulmonary  Tuberculosis — Secondary  Infection — Cures 
— What  Factors  hold  Tuberculosis  Latent — Climate  and  Environ- 
ment— Pulmonary  Hemorrhage  and  Altitude — The  Indians  as  an 
Object-Lesson — Relieving  Crowded  Centres — Sanitaria  and  Sana- 
toria and  Treatment — Common  Colds — Consumption  in  Hotels — 
Solitary  Life  Best — Altitude — The  Heart  and  Altitude — Diabetics 
and  Altitude — The  Climate  of  the  United  States  East  and  West — 
Sanatoria  and  Climate  in  Europe — Serum  Treatment  in  the  Adi- 
rondacks — Inhalations  as  Remedies 377 

CHAPTER    XII. 

Rheumatism  an  Infectious  Disease — The  Bacillus  of  Rheumatism — 
Thyroid  Extract  in  Rheumatism — Uric  Acid  in  Rheumatism — 
Nuclein — The  White  Blood-Corpuscles — Diagnosis — Treatment 
— Rheumatic  Gout — Multiple  Arthritis  Deformans — Gout — Ar- 
teriosclerosis—  Metabolism — Anabolism — Katabolism — Theories 

10 


CONTENTS 

I'AGK 

of  Gout — Origin  of  Uric  Acid — Causes  of  Gout — Gout  of  the 
Intestines — Treatment  of  Gout — Water — Lithia — Diet  in  Gout 
— Intermitting  Heart — Alcohol  in  Gout — Cider  Cure  for  Gout — 
Vegetables  in  Gout — Contracted  Kidney — Medicines  in  Gout — 
Piperazine  and  Pichi  in  Gout — Thyroid  Extract  causing  Gout 
— Menstrual  Gout — Carlsbad — An  American  Carlsbad — Diabetes 
Mellitus — Glucose  —  Starches  —  Dextrose  —  Glycogenic  Matter  — 
Tuberculosis  and  Diabetes — Pancreatic  Lesions — Carl  von  Noor- 
den — The  Liver  and  Glycogen — Fat — Hyperglyca^mia — Causes  of 
Diabetes  Mellitus — Mayer's  Theory — McCaskay's  Suggestions- 
Relationship  between  Diabetes  and  Obesity  and  Gout  and  Dia- 
betes— Gluten — Diagnosis — Tests  for  Sugar — Pregnancy  and  Dia- 
betes Mellitus — Alcohol — Recoveries — Diabetes  and  Gouty  Kidney 
— How  to  watch  a  Diabetic — Diabetic  Coma — Diabetics  Vulner- 
able— Diabetics  and  Tuberculosis — Thyroid  Treatment — Progno- 
sis— Diet  and  Treatment — Jambul  and  Piperazine — Substitutes 
for  Cane  Sugar — Wines  and  Spirits — Waters — Fruits — Nuts — 
Allowable  Articles  of  Diet — Terrapin — Rest  Treatment — Gluten 
Flours  and  other  Diabetic  Flours  and  Foods — Analysis  of  Maca- 
roni, Flours,  etc. — The  Soja  Bean — Aleuronat  Flour — Adultera- 
tions       418 


II 


FORTY    YEARS 


MEDICAL    PROFESSION 


¥¥ 


CHAPTER    I. 

Voyage  to  San  Francisco — The  Isthmus  of  Panama — The  Western 
Coast  of  Mexico — Arrival  at  San  Francisco— United  States  Marine 
Hospital,  San  Francisco — Diseases  among  the  Sailors — The  First 
Japanese  Embassy  to  the  United  States — R.  H.  Dana,  Jr. — San  Fran- 
cisco in  the  Early  Days — The  Medical  Profession — Duels — The 
Climate — San  Francisco  in  1894 — John  Chinaman. 

The  unexpected  frequently  shapes  a  man's  destiny.  In 
my  case  this  was  not  so,  for  my  paternal  grandfather  and 
my  father  were  both  well-known  practitioners  of  medicine 
in  Delaware.  For  this  reason  it  was  decreed  by  my  family 
that  I,  willing  or  unwilling,  should  also  become  a  physician. 

I  take  the  date  of  my  entry  into  the  profession  as  June  5, 
1858,  on  which  day  I  sailed  for  San  Francisco,  California, 
on  the  steamer  Moses  Taylor,  from  New  York.  The  ship 
was  a  side-wheel,  wooden  vessel,  with  two  walking-beam 
engines,  of  fair  speed,  but  a  notorious  roller,  and  very  un- 
comfortable in  a  rough  sea.  She  was  of  about  two  thousand 
tons  burthen,  and  as  she  carried  nine  hundred  passengers, 
besides  her  crew,  it  is  evident  how  overcrowded  and  uncom- 
fortable we  must  have  been,  especially  so  as  during  a  part  of 
the  voyage  we  were  exposed  to  the  intense  heat  of  the 
tropics.     The  voyage  w^as  uneventful  as  far  as  Aspinwall. 

13 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

There  we  were  landed  and  were  held  until  the  ship  could  be 
unloaded  and  the  passengers  transferred  across  the  Isthmus 
of  Panama.  At  this  time  yellow  fever  was  raging  in  Aspin- 
wall,  but  none  of  our  people  became  infected.  At  Panama 
we  were  embarked  upon  a  larger  steamer,  the  John  L.  Ste- 
phens, for  San  Francisco,  stopping  at  Acapulco  and  Man- 
zanillo,  Mexico.  We  received  additional  passengers  at 
Panama,  making  our  number  on  the  Stephens  fifteen  hun- 
dred in  addition  to  her  crew.  The  heat  in  the  tropics  was 
very  severe,  ice  on  the  ship  was  twenty-five  cents  a  pound, 
yellow  fever  was  raging  in  Acapulco,  and,  worse  than  all, 
small-pox  broke  out  among  the  passengers  on  our  ship. 
After  a  time  we  arrived  safely  at  San  Francisco,  and  I  only 
speak  of  these  matters  as  apropos  to  my  induction  into  the 
profession.  My  paternal  cousin.  Dr.  Richard  Tybout  Max- 
well, who  had  studied  medicine  with  my  father,  graduated 
at  the  University  of  Pennsylvania,  and  entered  the  United 
States  navy  as  assistant  surgeon,  had  remained  in  the  navy 
a  number  of  years,  and  like  many  other  army  and  navy 
officers,  had  resigned  as  full  surgeon  and  entered  upon  pri- 
vate practice  in  San  Francisco.  Dr.  Maxwell  took  me  as 
his  private  student  and  established  me  as  dresser  in  the 
United  States  Marine  Hospital,  San  Francisco,  of  which 
he  was  surgeon  in  charge.  I  was  just  fresh  from  Princeton 
College,  and  to  me  the  change  was  both  abrupt  and  novel, 
as  may  well  appear. 

In  those  days  the  marine  hospital  service  was  not  organ- 
ized, and  had  no  such  masterly  corps  of  surgeons  and  scien- 
tific men,  with  a  Wyman  at  their  head,  as  exists  to-day. 
The  surgeons  in  charge  were  generally  local  practitioners, 
appointed  by  the  Secretary  of  the  Treasury,  and  did  not 
reside  in  the  institution.  At  the  San  Francisco  Hospital,  a 
fine  large  building,  at  the  time  one  of  the  few  fine  ones  in 
the  city,  had  just  been  finished  by  the  government  with  a 
capacity  of  about  three  hundred  beds.  This  building  is  now 
used  as  a  sailors'  home,  and  has  been  so  much  shaken  by 
earthquakes  as  scarcely  to  appear  safe  as  an  abode  for  human 

14 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

beings.  The  government  lias  now  establisherl  a  new  hospital 
in  a  new  building,  out  on  the  Presidio  reservation,  near  the 
ocean,  where  the  sick  and  unfortunate  sailors  have  all  the 
advantages  of  the  well-regulated  marine  hospital  service  of 
the  present  day. 

To  go  back  to  the  old  hospital :  The  organization  was 
composed  of  the  surgeon  in  charge,  Richard  Tybout  Max- 
well ;  assistant  surgeon,  John  Young  Lind ;  steward,  Mere- 
dith A.  Sullivan ;  apothecary,  Frank  T.  Maynard ;  orderly, 
William  Lindop;  student  of  medicine,  John  Janvier  Black; 
together  with  a  corps  of  nurses  and  cooks  such  as  could  be 
held  together,  taken  generally  from  convalescent  patients, 
and  held  as  long  as  possible,  the  almost  daily  gold  excite- 
ment alluring  all  adventurers  to  the  new  fields,  and  those 
who  escaped  these  sirens  generally,  sooner  or  later,  fell  vic- 
tims to  the  sailor's  love  of  rum  and  its  attendant  excite- 
ment, and  in  their  maudlin  state  were  shanghaied  aboard 
some  departing  vessel,  and  only  recognized  their  helpless 
state  when  they  awakened  from  their  debauch  and  found 
themselves  far  out  on  blue  water,  bound  most  likely  on  a  six 
months'  voyage. 

A  case  recurs  to  me  here  worth  relating  as  showing  in 
glaring  colors  the  ups  and  downs  of  a  sailor's  life.  One 
morning  an  English  sailor,  a  magnificent  specimen  of  the 
physical  man,  was  brought  in  suffering  from  a  gunshot 
wound  of  the  right  shoulder.  James  Whitford,  I  well  re- 
member, was  his  name.  He  had  been  employed  as  a  runner 
of  a  sailors'  boarding-house,  kept  by  a  man  by  the  name  of 
Sheridan.  Whitford  stated  that  Sheridan  had  shipped  the 
men  on  the  English  clipper  Beau  Monde  for  a  long  voyage. 
To  carry  out  the  thrifty  designs  of  such  men  in  San  Fran- 
cisco in  those  days,  he  had  commissioned  WHiitford  to  go 
the  next  night  and  kidnap  the  same  men  from  the  Beau 
Monde  he  had  shipped  in  the  morning,  with  the  intention 
of  getting  another  advance  from  some  other  confiding  cap- 
tain, and  so  on  ad  infinituin. 

The  officers  of  the  Beau  Monde  were  looking  for  just 

15 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

such  trouble,  and  as  Whitford's  head  appeared  above  the 
rail  the  first  officer  shot  him  in  the  right  shoulder,  as  before 
stated,  and  down  he  dropped  into  the  bay,  but  was  rescued 
by  his  companions  and  brought  to  the  hospital. 

Whitford's  case  went  on,  and  was  a  most  interesting  one 
surgically,  one  that  probably  would  not  happen  now  in  the 
days  of  antiseptic  methods.  Sepsis  supervened.  Among 
other  troubles,  I  remember,  an  abscess  of  the  liver  developed, 
which  opened  through  the  diaphragm  into  the  lung,  and  the 
pus,  tinged  with  the  bile,  all  came  by  expectoration  through 
the  mouth.  A  large  abscess  developed  at  the  right  hip,  the 
head  of  the  femur  was  dislocated  and  absorbed,  and  the  head 
of  the  bone  made  a  new  socket  on  the  dorsum  of  the  ilium. 
After  probably  a  year  the  man  recovered,  with  a  shortened 
limb,  a  physical  wreck.  I  never  saw  in  any  human  being 
such  an  exhibition  of  brute  courage  and  strength  as  this  man 
possessed,  and  his  vindictive  nature  was  proved  by  the  sequel. 

After  he  left  the  hospital  he  went  back  to  Sheridan's 
sailors'  boarding-house  as  bouncer  and  bar-keeper.  Not  long 
after  he  had  taken  his  new  position  he  deliberately  shot  the 
proprietor  dead,  saying,  as  he  shot,  it  was  his  sweet  revenge 
for  the  ruin  Sheridan  had  brought  on  him  in  the  Beau  Monde 
affair.  After  a  trial  in  the  courts,  Whitford  was  judicially 
executed  by  hanging,  and  I  have  always  regretted  I  was  not 
at  hand  to  hold  a  post-mortem  over  the  remains.  I  have 
often  thought  that  many  a  fair  romance  has  been  builded  on 
a  series  of  circumstances  less  weird  than  those  surrounding 
the  life  of  this  unfortunate  sailor.  Man-of-war  discipline 
was  maintained  in  the  hospital,  which,  under  the  conditions, 
was  not  difficult;  sailors  are  accustomed  to  obey,  and  give 
little  trouble  usually.  Now  and  then  a  sea  lawyer  bobs  up 
among  them ;  throttle  him,  and  the  rest  is  easy.  The  govern- 
ment provided  amply  for  their  wants  in  all  respects,  and 
gave  them  more  comforts  and  a  better  home  than  they  ever 
obtained  elsewhere.  Although  at  the  present  time  they  are 
much  better  protected  from  sharpers  the  world  over  than 
they  were  in  the  days  I  am  writing  of,  they  are  at  best  an 

i6 


FORTY    YEARS    IN    TITE    MEDICAL    PROFESSION 

unfortunate  class  of  peo])lc,  never  having  1)ut  one  lianrl  with 
which  to  help  themselves,  the  other  going  to  the  owner,  as 
they  express  it.  The  ends  of  their  short  lives  generally  find 
them  struggling  with  the  angry  billows,  and,  whether  on  sea 
or  on  land,  little  it  matters  to  them.  The  clinical  material 
in  this  hospital  was  plenty,  diverse,  and  interesting.  The 
material  was  collected,  as  it  were,  from  the  world  over.  The 
venereal  wards  were  especially  ])rolific  in  acute  and  chronic 
cases.  Secondary  and  tertiary  syphilis  and  strictures  of  the 
urethra  were  very  common.  It  is  in  this  class  of  diseases 
that  poor  sailors  suffer  so  horribly.  They  ship  often  through 
ignorance,  but  generally  nolens  volens,  utterly  regardless  of 
their  condition,  and  they  either  die  at  sea  after  terrible  suffer- 
ing or  are  landed  at  the  end  of  the  voyage,  hopeless  wrecks 
and  cruel  sufferers.  Skin  diseases,  both  specific  and  non- 
specific, were  common,  and  the  clinical  material  in  parasitic 
diseases  was  especially  abundant  and  interesting.  Jiggers, 
the  tropical  penetrating  fleas,  the  guinea- worms  {Filaria  me- 
dinensis),  and  the  dififerent  tape-worms  were  very  common. 
Scurvy  was  a  frequent  disease  among  those  admitted.  It 
was  common  at  that  day  on  our  own  merchant  ships,  out  on 
long  voyages,  and  also  on  the  French  and  German  ships. 
Few  if  any  cases  came  from  the  English  ships.  All  sailors 
arriving  in  those  days  from  long  voyages  were  in  probably 
a  slightly  scorbutic  condition,  but  not  out  of  health  suffi- 
ciently to  apply  for  relief  in  a  hospital.  It  would  be  better  if 
all  sailors  were  taken  in  charge  by  some  friendly  hand  at  the 
end  of  long  voyages,  for  if  not,  they  usually  go  on  a  debauch 
and  reship,  and  are  in  no  wise  built  up  after  the  long  priva- 
tions of  the  previous  voyage.  This  is  one  great  reason  of 
their  broken  health  and  short  lives  as  a  class. 

I  never  saw  scurvy  among  the  officers  of  the  ships.  This 
showed  the  cause  in  a  great  measure.  All  the  men  got,  as  a 
rule,  was  salt  meat  and  hardtack,  now  and  then  a  little  duff, 
and  morning  and  evening  some  weak  cheap  tea  with  molas- 
ses. Six  months  of  such  diet  is  enough  to  sicken  any  man. 
Add  to  this  a  dreary  voyage,  quarters  often  cold  and  never 
2  17 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

dry,  never  a  cheery  word  from  any  one,  nor  a  morsel  of  food 
but  what  is  almost  distasteful,  from  frequent  repetition  of 
the  same  stuff,  and  you  have  all-sufficient  causes  for  scurvy. 
The  symptoms  then  were  the  same  as  now, — the  spongy  and 
bleeding  gums,  the  loose  teeth,  the  iron  hardness  of  the 
muscles,  especially  the  calves  of  the  legs,  the  petechial  hem- 
orrhages, the  foul  breath,  and  the  great  and  general  weak- 
ness of  the  individual.  The  tendency  to  hemorrhage  was 
frequent  and  persistent,  and  the  blood  dark  and  thin.  Of 
course,  at  that  day  no  thought  was  given  to  it  as  now  as  a 
disease  of  infection  and  possibly  of  microbic  origin.  The 
circulation  in  the  sailors'  cases  was  weak  and  the  heart  often 
irregular.  We  found  the  first  great  remedy  to  be  recum- 
bent rest.  I  once  saw  a  fine  physical  specimen  of  a  man 
brought  in  with  others  of  a  crew  infected  with  scurvy.  He 
got  up  to  walk  across  the  ward,  and  fell  dead.  Post-mortem 
showed  no  lesion  of  organs  to  account  for  death.  Exhaus- 
tion was  the  cause.  Had  he  been  kept  on  his  back  for  a  few 
days,  he  would  in  all  probability  have  recovered.  This  case 
has  ever  after  been  a  lesson  to  me  to  conserve  the  strength 
of  a  weak  patient,  the  need  of  watchful  care  to  those  ex- 
tremely ill.  Fresh  vegetables,  oranges,  lemons,  and  the  like, 
giving  their  salts  as  citrates  and  such  in  the  digestive  tract, 
fresh  meats,  and  the  salts  of  potash  direct  in  the  shape  of 
potash  bitartrate  were  the  usual  remedies  used,  with  the  best 
success. 

We  had  patients  from  every  clime,  and  here  was  a 
good  place  to  study  racial  characteristics.  An  interest- 
ing group  was  that  from  the  Japanese  Embassy,  which 
came  over  after  old  Commodore  Perry  had  opened  up 
the  ports  of  Japan  to  the  outside  world.  They  came  to 
San  Francisco  on  their  way  to  Washington  in  the  old  side- 
wheel  frigate  Powhatan,  under  the  care  of  distinguished 
officers  of  our  own  government.  Many  of  the  servants 
were  ill  after  their  arrival  in  San  Francisco  with  acute 
pulmonary  troubles.  All  these  fell  to  us  in  the  hospital, 
and  we  appropriated  a  large  ward  to  their  use.     We  could 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

not  do  much  with  them  at  that  day.  They  were  just 
coming  out  of  their  seckision  of  centuries,  and  were  very 
suspicious  of  outsiders,  and  particularly  of  doctors  and  medi- 
cines. Several  died,  and  were  buried  by  their  own  peculiar 
ceremonies.  The  cadavers  were  continually  guarded  until 
burial,  and  never  a  coffin  was  lowered  into  the  grave  until 
the  lid  had  been  lifted  as  a  last  precaution.  The  redoubtable 
Japanese  Tommy  was  with  this  commission,  a  bright,  rest- 
less little  mortal,  and  a  frequent  visitor  to  the  hospital ;  but 
no  time  to  be  sick  had  Tommy.  Those  with  us  were  in- 
veterate gamblers,  great  smokers,  and,  as  they  grew  to  better 
health,  quite  jovial,  yet  always  suspicious,  reserved,  and  sly. 
Of  course  they  gambled.  They  were  all  men  of  one  sword. 
They  gambled  among  each  other,  not  with  our  men.  At  last 
one  or  two  of  the  Japs  had  about  won  everything  all  the 
others  of  the  party  possessed.  Then  their  cunning  came  in. 
They  sold  nearly  everything  they  had,  even  their  swords,  to 
the  hospital  employees.  When  their  resources  from  this 
manoeuvre  were  gone  they  had  come  to  their  wits'  end. 
They  came  to  the  hospital  authorities  to  interfere  to  have 
their  property  returned,  for  if  they  went  back  to  Japan  sword- 
less,  each  swordless  man  must  then  and  there  commit  liari- 
kari.  The  ruse  was  successful,  but  had  the  embassy  remained 
I  have  no  doubt  the  same  process  would  have  been  gone  over 
again  ad  iniinitum.  These  people  brought  their  own  food, 
and  ate  none  of  ours.  They  lived  on  rice,  tea,  and  what 
looked  like  a  persimmon  pickled  in  brine,  and  eaten  with 
their  rice.  In  a  medical  way  we  learned  little  of  them  or 
from  them.    To-day  what  advances  these  people  show" ! 

I  remember  another  very  interesting  visitor  to  the  hos- 
pital,— Richard  Henry  Dana,  Jr..  author  of  "  Two  Years  Be- 
fore the  Mast,"  that  greatest  of  sea-tales,  and  for  the  writing 
of  which  every  man  who  has  been  a  sailor  or  who  has  had 
to  do  with  sailors  should  doff  his  hat  at  the  mention  of  Dana's 
name.  That  book  started  the  crusade  which  has  done  so 
much  to  right  the  sailor's  wrongs  and  to  ameliorate  his  for- 
mer deplorable  condition.     Dana  was  on  his  way  around  the 

19 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

world,  and  this  was  his  first  visit  to  the  Pacific  coast  since  he 
left,  at  the  end  of  his  memorable  voyage  of  "  two  years  before 
the  mast."  He  made  a  rigid  inspection  of  the  hospital  and  all 
that  pertained  to  it.  He  knew  how  to  inspect :  he  went  to 
the  nooks  and  the  corners,  to  the  beds,  the  clothing,  the  drain- 
age, the  food  supply,  the  tables,  the  dishes,  especially  the 
cups,  the  spoons,  before  and  after  they  had  been  washed. 
The  grounds  received  his  careful  attention ;  in  fact,  the  whole 
plant  and  its  contents,  patients  and  all,  were  thoroughly 
looked  over.  He  was  a  pleasant,  genial  gentleman.  I  had  a 
pleasant  time  with  him  on  several  occasions,  and  said  good-by 
for  the  last  time  as  he  passed  over  the  rail  of  the  clipper  ship 
Mastiff,  en  route  for  China,  on  his  way  around  the  world. 
The  Mastiff  was  loaded  with  Chinamen,  living  and  dead,  on 
their  way  back  to  the  Flowery  Kingdom.  In  their  proverbial 
recklessness  with  fire,  they  fired  the  ship  three  days  out  from 
San  Francisco.  All  had  to  take  to  the  boats.  In  a  day  or 
two  they  were  rescued  by  an  English  ship  bound  for  China, 
and  were  there  landed  safely  at  the  end  of  her  voyage,  or 
rather  at  Honolulu,  where  she  stopped  en  route.  This  was 
great  good  luck,  as  in  those  days  seldom  a  ship  sighted  an- 
other on  that  voyage. 

The  first  major  operation  in  surgery  I  saw  was  an  ampu- 
tation at  the  hip- joint  upon  a  poor  fellow  brought  in  for 
crushed  limb,  caused  by  an  accident  in  a  steamboat's  engine. 
The  limb  was  fearfully  mangled,  and  the  femoral  vessels 
being  exposed  made  their  ligation  easy,  as  a  preliminary  to 
the  disarticulation.  I  was  given  the  responsible  position  of 
holding  the  limb,  and  thus  my  initiation  as  a  saw-bone  was 
a  formidable  one.  Dr.  Maxwell  did  the  operation  very  dex- 
terously, making,  rather  from  necessity,  lateral  flaps  of  skin 
and  muscle.  The  poor  fellow  died  in  a  few  hours,  of  exhaus- 
tion. I  remember  it  was  discussed  at  the  time  whether  or 
not  the  operation  was  proper  under  the  circumstances.  The 
man  rallied  sufficiently  and  lived  long  enough  to  compel 
action,  and  the  operation  was  decided  to  be  justifiable.  I 
have  since  been  placed  in  a  similar  position,  and  operated 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

with  like  result,  but  believe  1  was  justified.  There  have  been 
few  recoveries  fnjni  primary  ani[)utations  at  the  hip  for  ac- 
cident or  gunshot  wouiul,  but  a  surgeon  may  be  called  upon 
to  give  the  patient  the  glimmering  chance  even  in  such  des- 
perate emergencies. 

In  those  days  San  Francisco  was  a  new  mushrofjm  West- 
ern town,  cut  off  almost  entirely  from  the  outside  world,  the 
mails  only  coming  twice  each  month  by  the  Pacific  Mail 
steamers  via  Panama.  The  town  then  was  mostly  built 
along  the  Bay  of  San  Francisco  on  made  ground ;  the  streets 
were  either  sand  ways  or  planked  with  wood,  with  a  popula- 
tion of  less  than  forty  thousand  souls. 

There  were  many  refined  and  cultivated  people  living  there, 
quite  a  number  of  United  States  army  and  navy  people, 
among  them  young  men  who  afterwards  became  famous, — 
Halleck,  McPherson,  Ogden,  Sawtelle,  Mackall,  Keys,  Mur- 
ray, Alden,  and  others.  There  were  also  many  refined 
English,  French,  Germans,  old  native  Californians,  and 
Mexicans.  The  tone  of  the  medical  profession  was  not 
highly  elevated.  There  were  bickerings  and  jealousies 
among  the  members,  composed  as  it  was  of  men  of  nearly 
all  nations  and  gathered  from  all  parts  of  the  world.  The 
business  was  profitable  to  those  in  full  practice,  but  living 
expenses  were  great.  The  fees  were  from  three  to  five  dol- 
lars each  visit,  with  surgical  and  other  special  services  in 
proportion.  Among  the  more  prominent  men  were  R.  T. 
Maxwell,  H.  H.  Toland,  Thomas  Bennett,  F.  A.  Holman, 
Benjamin  Coit,  John  Hastings,  E.  S.  Cooper,  L.  C.  Lane, 
R.  Beverly  Cole,  Charles  Bertody,  H.  M.  Gray,  Augustus  J. 
Bowie,  Isaac  Rowell,  J.  M.  McNulty,  Robert  K.  Nuttall, 
William  Hammond,  and  A.  B.  Stout. 

I  give  these  names  here  as  a  contribution  to  the  history 
of  the  profession  in  a  town  now  become  the  metropolis  of 
the  Pacific  coast,  and  really  one  of  the  medical  centres  of 
the  Western  world.  Maxwell  was  a  retired,  or  rather  a  re- 
signed, naval  surgeon,  who  took  up  civil  practice  in  San 
Francisco  in  1854.     He  was  an  able  man,  a  good  all-round 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

medical  man.  He  was  a  fine  operator,  and  especially  excelled 
in  gehito-iirinary  surgery.  In  obstetrics  he  had  a  deservedly 
large  practice.  He  had  decided  artistic  talent,  painted  well 
in  oil,  and  was  a  fine  musician  and  linguist.  He  died  in  1883. 
Toland  had  a  very  large  practice,  was  quite  a  surgeon,  and 
made  a  large  fortune.  He  founded  the  Toland  Medical  Col- 
lege in  San  Francisco,  now  connected  with  the  University 
of  California,  and  died  some  years  ago.  Thomas  Bennett 
was  an  Englishman,  a  man  of  fine  presence,  well  educated, 
and  a  good  all-round  doctor.  He  is  deceased  several  years. 
F.  A.  Holman  was  a  fine  man  and  a  very  good  surgeon. 
Coit  and  Hastings  were  general  practitioners,  the  latter  the 
author  of  a  "  Dissector's  Manual."  E.  S.  Cooper  was  a  re- 
markable man,  of  decided  talent,  and  very  ambitious.  He 
was  very  aggressive,  and  started  out  as  a  surgeon  exclusively. 
In  1858  he  founded  the  first  medical  school  on  the  Pacific 
coast,  the  Cooper  Medical  College.  From  this  beginning  has 
grown,  greatly  owing  to  the  munificence  of  Dr.  L.  C.  Lane, 
Dr.  Cooper's  relative,  the  present  Cooper  Medical  College 
and  Lane  Hospital.  Dr.  Lane  is  a  very  prominent  surgeon, 
and  has  been  such  for  many  years  on  the  Pacific  coast,  as 
the  successor  of  Dr.  Cooper,  who  died  comparatively  a  young 
man  many  years  ago.  Dr.  Cole  is  still  prominent,  particularly 
as  a  gynaecologist.  Bertody,  Gray,  Bowie,  and  Rowell  have 
passed  away.  Rowell,  I  think,  was  Professor  of  Chemistry 
in  the  Cooper  school  in  the  early  days.  He  was  Broderick's 
surgeon  in  the  famous  duel  between  him  and  Judge  Terry, 
when  Broderick  received  his  death  wound.  I  remember,  the 
ball  struck  him  in  the  upper  part  of  the  chest,  embedded  itself 
in  the  soft  parts,  and  was  extracted  the  second  day.  Sepsis, 
with  its  usual  train  of  symptoms,  followed,  and  in  a  few  days 
Broderick  passed  away. 

Duels  were  common  there  in  those  days,  but  this  one, 
owing  to  the  prominence  of  the  parties, — one  a  United  States 
Senator  and  the  other  a  judge  of  the  State  Supreme  Court, — 
created  much  comment,  the  cause  being  disagreement  on  na- 
tional politics. 


FORTY    YEARS    IN    THE    MEDICAL    PROEESSION 

McNulty  was  a  very  fine  man,  who  is  still  living  in  South- 
ern California.  Nuttall  is  long  since  deceased.  Hammond 
was  an  old  army  surgeon,  a  man  of  decided  talent,  had  a  fine 
practice,  and  I  think  is  still  living,  retired,  out  of  the  city. 
Stout  is,  or  was  recently,  living,  a  very  old  man.  He  was  a 
very  able  man,  and  one  of  the  best  surgeons  (mi  the  coast. 

In  the  early  days  San  Francisco  was  a  healthy  town,  and 
surgical  cases  did  well,  owing  to  the  cool  and  dry  climate, 
sandy  nature  of  the  soil,  natural  drainage,  and  salt  water  sur- 
roundings. Paludal  malaria  was  almost  unknown,  and 
zymotic  diseases  were  quite  rare.  Pulmonary  troubles  and 
catarrhal  troubles  generally  were  common,  and  renal  disease 
was  very  prevalent,  this  being  due  to  the  climatic  conditions; 
the  average  temperature  being  about  60°  F.,  the  skin  did 
little  work,  and  threw  the  onus  on  the  kidneys.  Free  living 
of  the  people  was  an  additional  factor  as  to  renal  troubles. 
Gunshot  wounds  were  frequent,  but  machinery  accidents  rare, 
as  there  was  so  little  manufacturing  done  in  the  city.  Of  the 
forty  thousand  people,  ten  per  cent,  were  probably  Chinese. 
Towards  the  ocean  there  was  little  beyond  Vallejo  Street, 
and  in  the  opposite  direction  South  Park  was  the  built-up 
limit.  To  the  west  there  was  little  beyond  Taylor  Street, 
and  the  docks  were  confined  between  Vallejo  and  Harrison 
Streets.  The  churches  and  schools  and  other  public  buildings, 
compared  with  those  of  to-day,  were  crude,  but  served  their 
purpose  well,  and  were  a  happy  leaven  in  the  seething  caul- 
dron of  wickedness  at  that  day  rampant.  The  climate  then 
is  the  climate  of  to-day :  for  the  strong  and  vigorous,  per- 
fection; where  to  merely  breathe  and  exist  is  perfect  bliss; 
where  it  is  never  hot ;  where  it  is  never  cold ;  where  the 
woman  never  puts  away  her  seal-skin  nor  the  man  his  top 
coat;  where,  if  it  is  too  hot  in  the  sun  it  is  too  cool  in  the 
shade ;  where  it  is  pleasanter  in  winter  than  it  is  in  summer ; 
where  for  six  months  in  the  year  a  windmill  is  as  sure  a 
source  of  power  as  a  steam-engine;  where  it  is  apt  to  rain 
any  day  at  any  minute  for  six  months  in  the  year,  and  during 
the  other  six  months  no  cloud  mars  the  horizon ;    where  the 

23 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

north  wind  holds  sway  and  the  sea  fog  moistens  the  verdure 
ahnost  nightly,  a  potent  aid  to  the  irrigation  constantly 
needed  by  all  growing  plants  and  forest  growth. 

After  an  absence  of  thirty-four  years  I  visited  San  Fran- 
cisco for  the  second  time,  in  the  spring  of  1894.  Instead  of 
the  discomforts  of  a  sea  voyage  in  an  overcrowded  ship 
through  the  tropics,  I  crossed  the  continent  in  a  Pullman  car, 
surrounded  by  all  the  luxuries  of  modern  travel.  Surprised 
and  enchanted  at  the  growth  of  the  country  from  the  Atlantic 
seaboard  on  through  the  West,  we  entered  California  in  the 
Sierra  Nevadas,  my  last  recollection  of  which  was  racing  a 
storm  for  shelter  more  than  thirty  years  before.  On  through 
forty  miles  of  snow-sheds,  we  cross  the  great  mountains, 
and  in  two  hours  or  little  more  from  the  time  we  could  jump 
into  snow-banks  over  our  heads  we  could  alight  from  the 
cars  and  pick  oranges  from  the  trees.  Passing  down  the 
beautiful  Sacramento  Valley,  through  the  lovely  town  where 
the  palm  and  the  olive  grow  side  by  side  in  the  open  air,  on 
to  Oakland,  crossing  at  Benicia  in  the  largest  ferry-boat  in 
the  world,  we  come  face  to  face  with  the  modern  metropolis 
of  the  Pacific.  When  I  had  last  been  in  Oakland,  it  was  a 
mere  hamlet ;  I  found  it  now  a  beautiful  and  prosperous  city 
of  one  hundred  thousand  people.  Crossing  on  another  mag- 
nificent ferry-boat,  I  landed  at  Market  Street,  San  Francisco. 
What  a  change  from  the  passiveness  of  years  before !  Here 
are  extensive  buildings  for  the  railroads  and  ferries,  and  the 
rendezvous  of  probably  the  first  and  best  system  of  cable 
roads  in  the  world.  It  is  wonderful  how  they  move  up  and 
down  the  very  steep  hills ;  some  of  them  a  horse  can  scarcely 
crawl  up,  and  until  one  becomes  accustomed  to  it  there  is 
great  soreness  of  the  muscles  of  the  abdomen  and  back  caused 
by  holding  on  and  exercising  muscles  not  accustomed  to 
action  in  such  a  degree  as  holding  on  in  the  cable  car  causes. 
A  course  of  massage  for  vigorous  exercise  of  these  muscles 
as  a  preliminary  to  San  Francisco  cable-car  riding  would  be 
a  proper  proceeding.  Two  cars  generally  run  together, — a 
motor  car,  open,  and  a  trailer  car,  closed.     The  open  car  is 

24 


FORTY    YEARS    IN    THE    MI':i)ICAL    PROFESSION 

enticing,  but  the  newcomer  should  sit  in  the  sun  when  prac- 
ticable, and  protect  the  throat,  or  very  annoying  colds  are 
sure  to  follow.  There  is  no  better  way  to  get  a  view  of  the 
city  than  by  going  over  the  hills  by  the  numerous  cable  lines. 
These  lines  are  already,  in  a  measure,  being  competed  with  by 
electric  lines.  Some  say  the  hills  generally  are  too  abrupt 
for  electric  roads.  I  doubt  it.  The  possibilities  of  electricity 
have  been  by  no  means  reached  as  a  source  of  motive  power 
in  such  matters. 

There  are  now  in  the  city  probably  three  hundred  and  fifty 
thousand  people, — ten  per  cent,  still  Chinese.  There  are  over 
one  hundred  and  twenty-five  miles  of  paved  streets,  fifty 
banks  or  more,  eighty  public  schools,  over  three  hundred 
churches,  twenty-four  parks,  about  twenty  theatres,  and 
thirty  hospitals.  The  annual  rain-fall  is  about  twenty-five 
inches.  The  mean  temperature  is  about  56. 5  "^  F. ;  average 
maximum  temperature,  62.4°  ;  minimum  temperature,  50.7^  ; 
highest  temperature  on  record,  100°  ;  lowest,  29°  ;  clear  or 
partly  cloudy  days  each  year,  283  ;  cloudy  days,  82 ;  number 
of  days  on  which  rain  falls  each  year,  average,  70.  These 
statistics  show  an  average  of  twenty  years,  and  are  interest- 
ing in  a  medical  point  of  view. 

The  hotels  are  among  the  very  finest  in  the  world,  and 
living  in  them  is  comparatively  cheap.  The  Palace  Hotel — 
if  it  has  a  rival  in  the  world,  it  is  the  Waldorf-Astoria,  in 
New  York — is  a  grand  monument  to  the  enterprise  of  Ral- 
ston and  Sharon.  Its  location,  the  intersection  of  Market 
and  Montgomery  Streets,  is  the  liveliest  place  in  the  city,  and 
the  din  and  confusion  there  cause  one  to  imagine  himself  in 
the  very  busiest  centres  of  New  York  or  London.  House- 
rents  are  not  high  and  the  necessaries  of  life  are  not  dear,  a 
contrast  to  years  ago,  when  I  have  paid  fifty  cents  for  two 
apples.  I  believe  one  can  to-day  live  cheaper  and  live  well  in 
San  Francisco  than  in  any  other  large  town  in  the  country. 
Servants'  wages  alone  are  high.  At  the  best  hotels  you  can 
live  on  the  American  plan  at  a  very  low  rate.  Those  who  know 
how  to  live  well,  I  think,  prefer  the  European  plan,  and  have 

25 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

a  few  choice  dishes,  well  cooked  and  well  served.  You  may 
get  a  thoroughly  good  breakfast  table  d'hote  for  fifty  cents 
and  dinner  for  one  dollar.  The  Palace  serves  a  good  table 
d'hote  dinner  with  wine  for  one  dollar  and  twenty-five  cents. 
At  the  restaurants  one  may  imagine  himself  in  Paris.  One 
may  breakfast  a  la  fourchette  for  almost  any  sum  up  to  one 
dollar  and  twenty-five  cents,  all  with  wine.  The  fifty-cent 
dinner  at  the  French  restaurants  is  really  a  good  one  of  its 
kind,  with  a  red  or  white  native  ordinary  wine.  You  will  get 
a  soup,  a  fish,  an  entree,  a  joint,  with  vegetables,  a  salad,  a 
sweet,  cheese,  coffee  and  cognac,  service  and  attendance  by 
Frenchmen ;   and  it  is  good. 

Of  the  better  California  wines,  if  you  want  them,  you  can 
get  a  half-bottle  of  Zinfandel,  Riesling,  Mont  Rouge,  or  Sau- 
terne  for  fifty  cents,  a  good  red  or  white  Burgundy  for  sev- 
enty-five cents,  and  native  champagne  for  seventy-five  cents. 
I  doubt  if  true  fermented  champagne,  strange  as  it  may 
appear,  is  yet  made  in  California.  The  foreign  wines  sell  for 
about  the  same  prices  as  they  do  the  world  over,  and  the 
Californian  is  much  given  to  them,  to  the  exclusion  of  the 
native  wines.  Notwithstanding  this,  with  experience  in  the 
fining  and  refining  of  the  soil,  California  is  bound  to  become 
a  great  wine  country.  Beer  still  flourishes  there  to  a  greater 
extent  than  one  would  suppose  in  a  wine-producing  country. 
It  is  the  drink  of  the  masses.  Wine  may  be  aristocratic.  I 
know  of  no  better  reason.  This  wine  business  in  California 
is  of  great  interest  to  the  medical  profession,  and  I  have  no 
hesitation  in  recommending  medical  men  to  look  them  up  in 
all  relations  as  to  their  medical  use. 

My  excuse  here  for  saying  so  much  about  San  Francisco 
and  California  is  that  it  is  properly  a  subject  for  physicians 
to  study.  So  many  of  our  patients  ask  our  advice  as  to  travel 
for  health  and  recreation,  and  we  cannot  know  too  much  of 
just  such  matters  as  I  am  writing  about  and  propose  to  write 
about  in  this  work  to  give  them  intelligent  advice  and  intelli- 
gent help.  The  markets  are  fine;  the  meats  are  good;  the 
game,  fish,  fruits,  and  vegetables  are  not  excelled  anywhere, 

26 


FORTY    YICARS    IN    Till':    MEDICAL    PROFESSION 

except  that  the  flavor  of  all  our  Eastern  fruits  and  vegetables 
is  superior  to  that  west  of  the  Allegheny  Mountains,  1  think. 
The  oysters  are  a  revelation.  I  pass  by  the  little  copi)ery 
native  oysters,  which  sell  for  forty  cents  ])er  hundred,  while 
the  Eastern  oysters  sell  for  about  the  same  price  per  dozen. 
They  are  not  successfully  propagated  in  the  California  waters, 
but  are  brought  as  small  ones  from  the  East,  transplanted  to 
good  beds,  and  are  soon  better  than,  or  certainly  not  inferior 
to,  the  best  Chesapeake  and  Delaware  oysters.  Here  we  see 
the  good  work  of  the  United  States  Fish  Commission.  In 
early  days  no  shad,  striped  bass,  nor  catfish  were  to  be  seen  in 
California.  Now  the  very  finest  shad  can  be  gotten  every 
month  in  the  year  at  reasonable  prices.  So  the  striped  bass, 
the  catfish,  and  the  carp.  The  only  criticism  I  heard  on  the 
Fish  Commission  was  that  they  had  introduced  carp.  The 
fishermen  called  it  a  hog,  and  accused  it  of  destroying  the 
spawn  of  other  more  valuable  food  fish.  This  may  be  a  libel 
on  the  carp,  but  in  my  opinion  no  man  need  wish  to  eat  it 
when  he  can  get  suckers. 

To-day  San  Francisco  keeps  up  her  well-earned  reputation 
for  hospitality.  Some  of  the  private  residences  are  among 
the  finest  in  the  world,  and  are  the  scenes  of  lavish  entertain- 
ment. Strange  as  it  may  appear,  a  great  many  of  the  finest 
houses  are  built  of  wood,  the  California  red  wood ;  indeed, 
the  great  majority  of  them.  There  are  probably  three  rea- 
sons for  this, — expense,  healthfulness  of  the  wooden  struc- 
ture, and  fear  of  the  effect  of  earthquakes  on  the  more  massive 
buildings.  The  San  Franciscan  will  not  acknowledge  that 
the  latter  reason  holds  true  now,  but  the  other  two  reasons 
probably  do.  The  dwelling  section  of  San  Francisco  is  a 
wooden  town. 

The  fire  limits  for  wooden  structures  are  being  curtailed 
every  year,  yet  very  slowly.  The  red  wood  is  not  inflamma- 
ble, it  burns  very  slowly,  and  fire  in  it  is  easily  subdued,  yet, 
with  the  high  winds  and  dry  weather,  the  fire  department 
must  be  very  efificient  to  serve  the  people  as  well  as  it  does  in 
keeping  down  destructive  conflagrations.     It  is  a  grand  or- 

27 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

ganization,  and  owns  a  half-million  of  real  estate,  many  steam 
fire-engines,  cisterns  for  water  where  necessary,  with  many 
horses  and  men.  Seeing  it  in  service,  one  notes  the  perfect 
discipline  of  men  and  horses,  and  absence  of  hurry  and 
bluster  too  often  seen  in  such  service,  and  one  learns  to  con- 
fide in  it  sincerely  when  it  comes  out  triumphantly  from  a 
roaring  fire  fanned  by  a  howling  gale  in  a  district  crowded 
by  frame  buildings  where  rain  has  not  fallen  for  months. 

Golden  Gate  Park  is  the  pride  of  the  city,  and  great  reason 
have  the  people  to  be  proud  of  it.  It  is  a  great  therapeutic 
factor,  doubtless.  One  thousand  acres  have  already  been  im- 
proved, reclaimed  from  the  sand  hills,  where  nothing  grew  at 
first  but  the  scrub  oaks,  and  where  the  sand  grass  and  lupine 
were  planted.  It  proved  better  ground  than  it  looked.  It 
was  only  necessary  to  haul  a  little  earth  and  a  little  long 
manure  and  use  plenty  of  water  in  this  alkaline  soil,  and 
plant;  nature  did  the  rest.  The  soil  looks  sterile,  if  not 
sterilized,  and  probably  adding  soil  in  small  quantity  starts 
up  nitrification. 

All  nature  expands  as  though  struck  by  the  magician's 
wand.  Here  the  herbage  and  the  arborage  and  the  flora  are 
superb.  No  description  can  do  them  justice.  It  is  a  paradise 
for  the  weary,  the  invalid,  the  horticulturist,  and  the  botanist. 
The  eucalyptus  tree  {Eucalyptus  globulus),  by  its  rapid 
growth,  has  aided  the  authorities  much  in  rapidly  developing 
the  park,  but  I  am  quite  sure  as  the  other  trees  grow  they  will 
have  to  remove  a  great  many  of  them,  for  by  its  power  of 
absorbing  and  evaporating  moisture  you  see  the  baneful  effect 
of  the  eucalyptus  on  all  surrounding  grass  and  foliage.  To 
some  its  balsamic  odor  is  agreeable,  and  it  is  undoubtedly 
health-giving,  and  I  trust  as  many  as  possible  may  be  spared. 
The  children's  playground  and  houses  are  monuments  of  fore- 
thought and  of  Mr.  Sharon's  generosity.  They  have  their 
nursery,  their  ponies,  their  donkeys,  all  free  as  air,  and  there 
are  no  signs  of  "  Keep  off  the  Grass."  The  park  is  never 
closed ;  policemen  patrol  it  day  and  night.  The  conserva- 
tories are  well  constructed  and  the  contents  admirably  classi- 

28 


FORTY    YEARS    IN    THE    MEDICAE    PROFESSION 

fied,  with  the  finest  colleclicjii  of  hej^onias  in  the  world.  The 
museum  of  natural  history  has  a  fine  collection,  and  is  well 
worth  a  visit,  and  must  prove  a  great  educator.  The  monu- 
ments to  Hallcck,  Rev.  Thomas  Star  King,  and  Key  serve  as 
a  beginning,  and  doubtless  many  more  will  appear  in  time. 
The  aviary  is  a  remarkable  exhibition,  and  only  possible  in 
such  a  climate.  It  is  of  wire  netting,  300  by  150  by  32  feet. 
It  contains  one  hundred  and  fifty  species  of  birds,  two  thou- 
sand of  them.  It  is  most  interesting,  and  a  great  educator  for 
all.  There  is  a  large  wind  shelter  on  Strawberry  Hill  within 
the  park,  where  those  who  drive  may  stop  for  the  grand  view 
it  affords,  with  shelter  from  the  driving  northwesters,  so 
common  to  the  summer  -months.  The  music-stand,  the  suspen- 
sion bridge,  the  deer  glen,  the  buffalo  pasture,  and  Roman 
bridge  all  go  to  complete  one  of  the  grandest  public  pleasure- 
grounds  of  the  world.  Sutro  Heights  and  the  Cliff  House 
are  resorts  much  frequented,  and  although  not  yet  strictly 
public,  they  afford  additional  opportunity  for  recreation  and 
amusement. 

The  Presidio,  the  old  Spanish  military  post,  contains  over 
fifteen  hundred  acres,  and  is  the  present  government  military 
post.  It  is  situated  in  the  northwest  suburbs,  and  slopes  to 
the  harbor,  and  is  an  additional  grand  breathing  space  for 
the  people.  It  overlooks  the  bay  and  the  other  government 
military  posts.  Fort  Point,  Point  San  Jose,  with  Alcatraz 
and  Angel  Islands.  The  Presidio  has  fine  grounds  well  laid 
out,  with  shade  and  ornamental  trees  and  flowers.  It  is  one 
of  the  most  desirable  of  all  our  army  posts  for  officers  and 
men. 

The  cemeteries,  when  compared  with  those  of  early  days, 
show  well  the  strides  the  city  has  made,  and  are  situated  near 
and  around  Lone  Mountain,  which  is  surmounted  by  a  cross 
visible  from  all  points.  I  think  this  cross  was  a  gift  from  the 
late  George  W.  Childs,  of  Philadelphia.  Here  are  Laurel 
Hill,  Calvary,  the  Masonic  Cemetery,  the  Odd  Fellows'  Ceme- 
tery, and  the  Chinese  Cemetery.  In  those  lovely  spots  are 
the  remains  of  many  of  those  who  made  San  Francisco  and 

29 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

California  what  they  are,  and  the  mausoleum  architecture 
displayed  is  worthy  of  the  grandeur  of  ancient  Rome.  Here 
repose  the  remains  of  Latham,  banker,  senator,  and  governor ; 
of  Larkin,  pioneer  among  pioneers ;  of  Maxwell,  Toland,  and 
Cooper,  eminent  in  medicine ;  McAllister,  father  and  son, 
learned  in  the  law ;  Hearst,  capitalist  and  senator ;  Broder- 
ick,  pioneer  and  senator;  Babcock,  the  merchant;  Folsom, 
the  soldier;  Sharon  and  Flood,  each  of  whom  had  gathered 
riches  beyond  the  dreams  of  avarice.  The  remains  of  these 
and  other  great  men  have  been  gathered  here  on  the  borders 
of  these  lovely  avenues,  and  under  the  shade  of  the  laurel  and 
the  oak  may  their  dust  forever  mingle  with  the  soil  of  the 
State  they  loved  so  much  and  served  so  well ! 

Coming  cityward  from  the  park,  we  pass,  on  Jackson  and 
Pacific  Streets,  the  beautiful  Pacific  Heights,  the  coming 
part  of  the  town  for  residences ;  where  the  air  is  pure,  loaded 
with  salt  and  ozone  from  the  ocean ;  where  the  view  is  lovely, 
embracing  mountain  and  sea  and  landscape  combined.  Here 
are  costly  residences  now,  the  kitchens  and  workrooms  on 
the  main  avenue,  while  the  dining-rooms,  libraries,  and  other 
desirable  apartments  are  in  the  rear,  where,  from  the  rapid 
descent  of  the  land,  the  view  is  unobscured.  Down  on  the 
water  front  we  see  the  wharves  and  docks  and  the  great  im- 
provements resulting  from  the  bulkheading,  over  which  the 
bitter  fight  was  made  many  years  ago.  The  torredo  has  been 
conquered ;  he  will  not  cross  a  crack  in  his  work,  and  the 
built-up  pile  made  by  starting  with  a  small  four  by  four  and 
building  up  with  one-inch  stuff,  and  coating  with  various 
compositions,  has  sounded  his  death  knell. 

There  is  only  one  thing  galling  to  the  American  as  he  looks 
over  the  scene, — the  general  absence  of  the  old  clipper  ships 
of  the  early  days  and  the  display  of  foreign  flags  on  most  of 
the  great  ships  now  in  the  docks  and  at  anchor.  The  Chinese 
quarter  of  the  present,  growing  from  the  nucleus  of  years 
ago,  has  extended,  and  taken  in  parts  of  the  city  where 
formerly  were  desirable  places  of  residence,  particularly  on 
Stockton  Street  beyond  Washington  Street.     Much  of  Sac- 

30 


FORTY    YEARS    IN    THE    MKDICAL    PROFESSION 

ramento,  Dii  Pont,  Pacific,  Jacksf)n,  and  Washington  Streets 
is  now  Chinatown.  In  a  step  we  go  from  Christendom  to 
Heathendom,  practically  from  a  typical  American  town  to 
the  middle  of  the  Flowery  Kingdom.  John  walks  in  the 
middle  o^  the  street  for  the  same  reason  he  wears  his  cue,  he- 
cause  he  did  so  at  home.  He  eats  smoked  ducks  hecause  he 
did  so  at  home ;  for  the  same  reason  he  gambles  and  smokes 
opium.  If  he  is  free  from  any  of  our  own  vices  and  many 
more,  we  fail  to  see  it;  if  he  has  any  virtue  unknown  to  the 
average  Chinaman  at  home,  it  is  not  apparent.  He  is  here, 
in  fact,  a  heathen  among  heathen,  and,  like  the  leopard,  can 
never  change  his  spots.  The  Argonauts,  the  Forty-Niners, 
keep  up  the  old  society,  have  built  a  fine  hall,  and  have  an 
abundant  capital  to  insure  the  endurance  of  the  organization, 
which  extends  from  father  to  son,  and  doubtless  the  sons  will 
be  found  ever  ready  and  willing  to  uphold  the  honor  and  dig- 
nity of  the  land  so  thoroughly  guarded  by  their  forefathers. 
Many  of  the  newspapers  of  the  early  times  still  hold  sway, 
reinforced  by  many  others,  both  able  and  influential.  The 
Bulletin,  a  creation  from  the  brain  of  the  martyred  King, 
fertilized  by  his  blood  lost  in  the  days  of  lawlessness  and 
passion,  still  sheds  a  brilliant  lustre  from  its  pages.  The  Call 
yet  lives,  having  grown  from  a  pigmy  to  a  giant.  The  Ex- 
aminer and  the  Chronicle,  creations  of  later  days,  join  the 
others  in  upholding  the  honor  and  the  dignity  of  the  Golden 
City,  whose  growth  no  one  can  estimate  who  knew  it  in  its 
infant  days,  and  whose  future  we  can  only  imagine,  consid- 
ering its  past.  We  can  measure  its  coming  greatness  by  no 
human  scale,  but  can  only  conceive  of  a  mighty  town  like 
Atlantis  risen  from  the  sea;  a  creation  of  the  magician's 
wand,  a  realization  of  an  Aladdin's  tale. 


31 


CHAPTER    II. 

University  of  Pennsylvania,  Medical  Department,  i860 — The  Buildings 
and  Conveniences  for  Faculty  and  Students— The  Faculty — The 
Lectures — The  Quiz  Classes  and  Students — University  Characters — 
Outside   Teaching — The   Course. 

In  October,  i860,  I  matriculated  in  the  Medical  Depart- 
ment of  the  University  of  Pennsylvania.  At  that  time  the 
buildings  were  situated  on  Ninth  Street  just  above  Chestnut, 
where  the  present  United  States  Post-Office  now  stands. 
There  were  two  buildings.  The  one  nearest  Chestnut  Street 
was  occupied  by  the  Medical  Department,  and  a  short  dis- 
tance from  it,  towards  Market  Street,  was  a  similar  building, 
occupied  by  the  Department  of  Arts.  A  high  iron  railing 
enclosed  the  whole  along  Ninth  Street,  and  there  was  no  gen- 
eral outlet  to  the  rear  of  the  buildings.  The  basement  was  oc- 
cupied by  the  rooms  for  the  Dispensary,  Clinics,  store-rooms, 
vat-rooms  for  cadavers,  etc.  There  were  three  general  lec- 
ture-rooms, one  used  by  the  Professors  of  Practice,  Materia 
Medica,  and  Physiology,  one  entirely  by  the  Professor  of 
Chemistry,  and  the  other  by  the  Professors  of  Surgery,  Ob- 
stetrics, and  Anatomy.  There  were  private  rooms  for  the 
professors  adjoining  the  lecture-rooms,  with  a  small  ward 
for  surgical  cases.  The  upper  floor  of  all  was  occupied  by  the 
dissecting-room,  next  to  Ninth  Street,  and  the  opposite  room 
was  devoted  to  the  classes  in  bandaging  and  practical  sur- 
gery. As  to  comforts  for  either  students,  or  even  the  pro- 
fessors and  their  assistants,  in  the  way  of  bath-rooms,  toilet- 
rooms,  or  general  wash-rooms,  there  were  none  worthy  of  the 
name.  Yet  they  were  in  general  keeping  with  such  as  were 
furnished  students  in  the  better  schools  and  universities  of 
the  day.  The  lecture-rooms  were  badly  lighted  by  day  and 
by  night,  and  the  ventilation  was  worse.     Princeton  College 

32 


FORTY    YEARS    IN    'illE    MEDICAL    PROFESSION 

was  no  better  in  the  way  of  such  comforts.  At  that  time  there 
was  not  a  decent  water-closet  connected  with  the  college,  and 
not  a  bath-room  in  the  whole  collection  oi  college  buildings 
in  Princeton.  More,  there  was  no  way  in  which  a  student 
could  get  a  drop  of  hot  water  except  by  heating  it  on  the 
stove  in  his  own  room,  and  in  the  North  College,  just  com- 
pleted, that  was  not  possible,  as  it  was  heated  by  hot  air,  with 
no  thought  of  a  bath-room  attachment. 

What  would  college  men  think  nowadays,  if  they  had  to 
do  their  bathing  in  individual  bath-tubs  in  their  own  rooms, 
as  we  did  who  were  college  men  forty  years  ago?  In  this,  as 
in  other  such  matters,  we  behold  the  evolution  of  a  civiliza- 
tion, and  almost  shudder  at  our  very  recent  release  from 
what  may  appear  now  as  a  near  approach  to  almost  savage 
existence.  At  the  University  the  benches  were  hard  and  un- 
inviting, and  the  rooms  were,  as  a  rule,  crowded.  Every 
one  took  matters  as  they  came,  and  good-humoredly,  and  as 
the  country  was  just  on  the  eve  of  the  great  convulsion  of 
the  Civil  War,  causing  great  unrest  in  all  matters  of  govern- 
ment and  finance,  no  one  had  as  yet  dreamed  of  the  great 
strides  and  advancements  in  store  in  the  comparatively  near 
future  for  the  grand  old  University  and  her  medical  school. 
The  head  of  the  faculty  at  this  time,  next  to  Professor  Jack- 
son, both  in  age  and  years  of  service,  was  Dr.  Hugh  L.  Hodge. 
He  was  nearly  blind,  and  excited  the  sympathy  of  every  one 
in  his  lectures  in  his  efforts  to  make  clear  his  demonstration. 
Hodge,  like  all  the  members  of  his  family,  was  a  great  man 
and  undoubtedly  one  of  the  foremost  obstetricians  of  his  day 
in  any  country.  Dr.  John  H.  Packard  generally  assisted  him 
at  his  lectures,  and  was  in  every  way  more  than  friend  to  the 
old  gentleman.  In  those  days  gynaecology  had  made  little  ad- 
vancement as  a  distinct  branch  of  surgery,  and  an  obstetrician 
rarely  took  up  a  knife  for  anything;  and  should  a  case  for 
Caesarean  section  present  itself  in  his  practice,  he  called  in 
the  general  surgeon  for  the  work.  Indeed,  not  to  have  done 
so  would  have  been  looked  upon  rather  as  a  breach  of  pro- 
fessional etiquette.  Dr.  Hodge  had  a  great  reputation  as  a 
3  33 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

gynaecologist  as  gynaecology  was  understood  in  those  days. 
He  referred  most  of  the  evils  of  the  female  organization  to 
irritable  uterus,  and  was  very  successful  in  the  treatment  of 
displacements  of  that  organ  with  the  pessary  bearing  his  name 
to-day  and  still  so  well  known  to  the  profession. 

I  remember  some  years  since  to  have  been  called  in  by  a 
very  aged  lady  to  consult  concerning  some  irritation  involving 
the  vagina  and  adjacent  parts.  Upon  examination  I  found 
a  mass  of  granulations,  and  embedded  in  it  some  hard  metal- 
lic-like substance.  I  questioned  the  patient,  of  course,  to  try 
to  find  out  the  cause  of  the  trouble.  She  told  me  Dr.  Hodge 
had  treated  her  for  some  time  more  than  twenty  years  before, 
and  she  thought  he  had  introduced  some  instrument.  The 
case  was  then  plain,  and  I  removed  the  encrusted  instrument 
by  cutting  it  into  segments,  and  her  trouble  soon  subsided. 

While  on  the  subject  of  pessaries,  one  case  comes  to  my 
mind  showing  the  quick  resourcefulness  of  that  great  sur- 
geon, the  late  Richard  J.  Levis.  A  professional  friend  came 
to  Levis  in  great  trouble,  saying  he  had  introduced  a  glass 
globe  as  a  pessary,  and  the  globe  had  from  some  cause  been 
broken  into  bits ;  and  how  to  get  it  out  without  mangling  his 
patient  he  did  not  know.  Levis  took  in  the  situation  at  once, 
procured  some  plaster  and  water,  filled  the  vagina  with  the 
mixture  of  proper  consistence,  allowed  sufficient  time  for  the 
setting,  then  removed  the  cast,  glass  and  all,  without  doing 
any  injury  whatever  to  the  grateful  patient. 

The  walls  of  the  vagina  are  very  prone  to  throw  out  gran- 
ulations and  bury  within  them  any  substance  which  may  by 
its  presence  offend  them.  Here  is  a  case  illustrating  this  point 
and  of  practical  application :  Some  years  since  I  applied  a 
Goddard  pessary  to  a  woman  for  a  complete  procidentia  uteri, 
and  made  her  entirely  comfortable,  as  these  instruments  often 
do.  Unexpectedly  I  did  not  see  her  for  some  years,  when  she 
applied  to  me  to  examine  the  condition  of  her  trouble.  Of 
course  these  instruments  should  be  removed  and  thoroughly 
cleansed,  and  if  necessary  renewed  at  shorter  or  longer  inter- 
vals.    In  this  case  I  found  the  external  bars  in  position,  but 

34 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

the  cup  and  part  of  the  stem  buried  in  g-ranulatif>ns,  which 
held  the  uterus  in  perfect  position.  My  first  thouglit  was  to 
cut  away  the  offencHng  growth  and  release  the  instrument, 
but  on  second  thought  I  cut  away  the  stems  and  then  took 
away  about  two-thirds  of  the  ring,  leaving  the  other  third  in 
the  mass,  holding  the  uterus  to  the  vaginal  wall.  Here  was  a 
perfect  correction  of  her  trouble.  I  examined  the  case,  at 
long  intervals,  several  times.  The  corrected  condition  re- 
mained perfect  until  she  died. 

To  return  to  Professor  Hodge.  He  published  a  work  on 
diseases  of  women,  according  to  his  views  of  the  matter,  and 
a  colossal  and  standard  work  on  obstetrics.  In  this  labor  he 
was  greatly  assisted  by  his  son,  the  late  eminent  surgeon  and 
cultivated  gentleman,  H.  Lenox  Hodge,  and,  as  he  himself 
has  said,  without  the  help  of  his  son,  on  account  of  his  own 
lack  of  eyesight,  the  book  would  never  have  been  written. 

William  Pepper,  Sr.,  father  of  the  late  distinguished  Pro- 
fessor William  Pepper,  Jr.,  was  Professor  of  the  Practice  of 
Medicine,  having  recently  been  elected  to  the  chair  made 
vacant  by  the  resignation  of  Dr.  George  B.  Wood.  Dr. 
Pepper  was  a  compactly  built,  rather  small  man.  He  was 
quick  in  his  movements  and  very  sprightly  and  earnest  as  a 
lecturer.  He  was  a  clear  thinker,  and  his  lectures  were  models 
of  their  kind,  for  in  those  days  the  course  only  lasted  about 
five  months,  and  to  condense  the  immense  amount  of  m'atter 
to  be  gone  over  successfully  in  that  short  time  required  both 
skill  and  ability.  Dr.  Pepper  had  a  great  aversion  to  the 
use  of  tobacco,  and  very  properly  attributed  many  ailments 
and  exaggerations  of  ailments  to  its  abuse.  In  summing  up 
the  causes  of  the  disease  he  happened  to  be  lecturing  upon,  we 
always  looked  for,  as  he  cast  his  eyes  over  the  class  with  a 

knowing  nod,   "  And,  gentlemen,  the  use  of  tobacco " 

While  Dr.  Pepper  was  a  most  interesting  and  successful  lec- 
turer, it  was  in  his  clinic  he  excelled.  He  was  a  masterly 
diagnostician,  and  it  was  a  real  treat  to  hear  and  see  him  go 
through  a  case  before  the  class.  He  had  a  thoroughly  edu- 
cated ear  and  a  wonderful  sense  of  touch,  each  trained  by 

35 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

faithful  study  and  practice  under  Louis.  He  labored  under 
great  disadvantages,  from  failing  health,  almost  from  the 
time  he  connected  himself  with  the  University.  He  made  a 
brave  and  manly  fight  to  the  end,  and  when  he  died  the  Uni- 
versity lost  a  devoted  teacher  and  the  profession  in  America 
one  of  the  ablest  of  the  many  very  bright  men  who  at  that 
period  adorned  it.  William  Pepper,  Jr.,  who  has  recently 
died  prematurely,  was  a  worthy  son  of  a  worthy  sire.  As  a 
young  man  in  hospital  life  in  Philadelphia  I  knew  him  well, 
as  I  did  his  brother  George,  another  bright  man,  who  died 
just  on  the  threshold  of  a  brilliant  career  as  an  obstetrician. 
William  Pepper,  Jr.,  was  a  man  of  fair  physique,  pleasing 
address,  and  polished  manners.  He  had  naturally  a  wonder- 
ful gift  of  language  and  facility  of  expression,  in  both  of 
which  he  expanded  as  he  grew  in  years  and  practice.  No 
doubt  he  had  exceptional  opportunities  in  his  chosen  profes- 
sion at  the  start,  but  no  man  ever  took  greater  advantages  of 
his  opportunities  or  used  them  more  successfully.  Not  only 
was  he  successful  beyond  measure  in  all  that  pertained  to  his 
life  as  a  physician  and  as  Professor  of  Medicine  in  the  Uni- 
versity of  Pennsylvania,  but  he  did  wonderful  work  in  build- 
ing up  and  developing  all  of  the  great  schools  connected  with 
the  University,  and  the  grandeur  of  his  work  in  this  direction 
is  well  worthy  of  a  lasting  remembrance.  Indeed,  the  great 
institution  of  to-day  may,  with  no  slight  to  other  men,  be 
said  to  be  at  once  his  work,  his  monument,  and  almost  his 
tomb,  for  doubtless  he  died  of  old  age  at  fifty-five,  from  over- 
work and  over-zeal,  both  as  a  physician  and  as  a  citizen  of 
Philadelphia,  the  city  of  his  birth,  the  town  he  loved  so  well 
and  did  so  much  to  honor  and  adorn. 

The  venerable  Samuel  Jackson  was  the  Professor  of  Physi- 
ology and  Institutes  of  Medicine.  Jackson  was  a  remarkable 
man,  and  probably  might  be  called  the  medical  philosopher 
of  his  day  among  the  medical  men  of  America.  He  was  a 
lovely  old  gentleman,  short  and  stout,  and  at  this  time  un- 
able to  walk  without  assistance.  I  cannot  say  much  for  his 
didactic  course  on  physiology,  for  his  lack  of  arrangement 

36 


FORTY    YEARS    IN    Tin<:    MICDICAF.    I'Rf^I'KSSIOiN 

and  common  method  rendered  it  ini])ossil)le  tf)  a])Sorl)  me- 
thodic knowledge  from  his  non-metho(hc  methods.  Many 
of  his  lectures  were  rare  treats,  and  the  mf)st  interesting  were 
when  he  started  on  some  subject  entirely  germruie  to  his 
course,  and  then  accidentally  branched  out  on  some  intercur- 
rent fact  that  came  up  by  accident.  He  was  fond  of  bringing 
up  facts,  clinical  facts,  from  his  large  experience  in  practice, 
and  often  charmed  his  listeners,  through  the  whole  hour  de- 
voted to  his  lecture,  by  a  dissertation  on  the  philosophy  of 
dreams,  or  the  localization  of  cerebral  functions,  or  some 
equally  interesting  subject.  The  old  gentleman  was  fortu- 
nately easy  in  his  examinations  for  degrees.  I  remember  the 
subject  of  my  own  thesis.  The  first  question  he  asked  was, 
what  was  the  subject  of  my  essay?  After  I  had  told  him  he 
launched  forth  and  gave  a  most  exhaustive  and  able  discourse 
on  the  subject,  making  me  feel,  I  remember  at  the  time,  that 
I  had  known  very  little  before.  This  took  some  time;  then 
he  asked  me  one  or  two  trifling  questions,  said,  in  a  very 
complimentary  way,  he  should  like  very  much  to  read  what  I 
had  written,  that  he  did  not  feel  very  w^ell  that  morning,  and 
politely  said  good-by. 

Dr.  Francis  Gurney  Smith  succeeded  Dr.  Jackson  in  the 
chair  of  Physiology.  He  was  a  rather  large,  fine-looking 
man,  of  fine  manners  and  address,  and  a  captivating  lecturer, 
one  of  the  very  best  among  the  faculty.  The  course  then 
was  a  very  simple  one, — about  three  didactic  lectures  a  week, 
with  absolutely  no  laboratory  or  experimental  work  on  the 
part  of  either  teacher  or  student.  Dr.  Smith  usually  wound 
up  his  course  each  winter  with  a  special  lecture  on  "Life  and 
Death."  It  was  beautifully  written  and  well  delivered,  and 
did  much  to  leave  a  good  impression  of  his  abilities  among 
the  students.  Dr.  Smith  died  a  comparatively  young  man, 
in  the  midst  of  his  work  and  well-earned  fame.  The  diasrno- 
sis  of  his  last  illness  had  a  pathetic  sadness  about  it.  and 
shows  well  the  protean  forms  of  renal  disease,  and  how  re- 
lentlessly and  stealthily  it  often  creeps  upon  us.  He  had  not 
deemed  himself  much  out  of  health,  and  had  taken  for  some 

37 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

reason  a  specimen  of  his  own  urine  to  compare  with  a  known 
diseased  specimen,  to  exhibit  before  some  students.  He  had 
shown  albumin  as  he  had  expected  to  find  it  in  the  diseased 
specimen,  both  by  Heher's  test  and  by  heat.  When  he  went 
to  show  the  different  reaction  in  his  own  heaUhy  urine,  he 
was  horrified  to  find  the  albumin  appearing  there.  The  reali- 
zation appeared  to  crush  him,  and  ever  after  until  his  decease 
he  appeared  far  from  well. 

Robert  E.  Rogers  was  Professor  of  Chemistry.  He  was  a 
fine  lecturer,  but  probably  not  so  brilliant  a  man  as  his 
brother,  who  had  preceded  him  in  the  same  chair.  He  had 
a  good  apparatus  at  the  University,  and  was,  as  a  rule,  very 
successful  in  his  experiments  before  the  class.  He  was  the 
Dean  of  the  Faculty,  and  thus  saw  much  of  the  students,  and 
was  always  personally  popular  with  them.  Several  years 
after  this  Dr.  Rogers,  who  was  much  given  to  experimenta- 
tion with  mechanical  matters,  lost  his  arm  in  a  washing-  or 
wringing-machine  in  the  West  Philadelphia  Military  Hos- 
pital. This  was  a  fearful  blow  to  him,  which,  together  with 
domestic  affliction,  greatly  marred  his  later  life.  For  reasons 
best  known  to  himself,  he  left  the  University  and  accepted 
the  proffered  Professorship  of  Chemistry  in  the  Jefferson 
school,  which  position  he  filled  satisfactorily  for  a  number  of 
years  before  his  death. 

Henry  H.  Smith,  a  tall,  commanding,  very  handsome  man, 
was  Professor  of  Surgery.  Dr.  Smith  had  been  a  private 
pupil  of  the  late  Professor  William  E.  Horner,  the  great 
anatomist  of  his  day,  and  afterwards  married  his  daughter. 
He  was  a  good  operator,  but  there  was  neither  the  brilliancy 
nor  the  blood  in  the  surgical  amphitheatre  of  the  University 
of  that  day,  such  as  one  saw  in  the  Jefferson  arena  during 
the  palmy  days  of  Pancoast  and  Gross.  Dr.  Smith  was  a 
careful  and  good  teacher,  and  in  his  clinics  one  saw  practice 
as  it  comes  to  us  every  day,  and  from  which,  after  all,  the 
pupil  absorbs  his  very  best  lessons. 

Joseph  Carson  was  the  Professor  of  Materia  Medica  and 
Pharmacy.     He  was  a  lovable,  pleasant  gentleman,  and  well 

38 


FORTY    YEARS    IN    THE    MEDICAL    I'ROEESSION 

grounded  for  the  work  in  his  special  branch.  To  many  stu- 
dents materia  medica  was  a  dry  subject;  this  was  much  owing 
to  insufficiency  in  their  preliminary  training  in  clicmistry  and 
botany.  Dr.  Carson  had  prepared  a  syllabus  of  the  subject, 
or  rather  a  synopsis,  which  was  a  help  to  his  students.  He 
was  fond  of  a  joke,  but,  strange  to  say,  he  could  never  suc- 
cessfully get  off  one;  he  wanted  to  laugh  himself,  and  laughed 
too  soon.  The  joke  nearly  always  stuck  in  his  throat,  and 
left  him  disconcerted  and  embarrassed.  One  of  his  choicest 
was  his  mercury  joke, — hydrargyri  chloridum  mite  and  hy- 
drargyri  chloridum  corrosivum,  "  but,  gentlemen,  I  assure 
you  there  is  a  mite  difference  between  the  two  substances." 

Joseph  Leidy  was  Professor  of  Anatomy.  Leidy  was  a 
famous  man.  In  all  that  pertains  to  nature,  whoever  was 
second,  Leidy  was  surely  first.  His  reputation  was  world- 
wide, and  when  he  died  the  whole  world  lost  one  of  her 
brightest  and  greatest  men.  Probably  in  no  place  of  all  places 
of  honor  he  held,  did  he  appear  to  less  advantage  than  as  a 
didactic  lecturer  to  students  on  anatomy.  Anyhow,  the  di- 
dactic lecture  has  had  its  day.  At  the  present  time  it  is  no 
way  to  teach  medicine,  and  is  fast  losing  ground,  as  it  should, 
and  soon  I  trust  we  shall  hear  it  no  more  in  the  halls  of  medi- 
cal science.  As  a  student  I  learned  much  more  in  the  quiz 
than  I  ever  learned  from  didactic  teaching.  It  has  been  ever 
so,  and  will  be  ever  so.  Let  us  empty  the  cerebral  blood- 
vessels of  didactic  instruction ;  let  us  eliminate  its  toxines  and 
come  to  rational  proper  methods  of  teaching.  There  was 
little  spice  in  his  talk,  and  he  invariably  impressed  me  as  one 
who  was  lecturing  as  a  means  by  which  to  live,  and  not  as 
one  who  lived  to  lecture.  He  was  no  surgeon,  and  applied 
anatomy  had  no  place  in  his  teachings,  yet  the  acknowledged 
greatness  of  the  man  inspired  his  listeners,  for  whatever  word 
Joseph  Leidy  uttered  in  a  scientific  atmosphere  could  but  in- 
spire his  hearers.  He  generally  told  of  his  experience  in  prac- 
tice, and  limited  it  to  one  case.  He  had  opened  an  office  soon 
after  graduating,  when  a  w^oman  came  in  with  her  child  with 
a  grain  of  corn  in  its  ear.    "  Well,  gentlemen,"  he  would  ask, 

39 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

"  did  I  hurry  ?  Was  there  an  anatomical  reason  for  hurry  ? 
No;  remember,  gentlemen,  the  corn  could  not  get  into  the 
child's  brain,  as  the  mother  feared,  but  I  feared  it  might  drop 
out  without  my  assistance  before  I  got  my  dollar."  Here 
was  applied  anatomy  for  you,  anyhow,  but  Leidy  never  gave 
us  much  more.  This  mere  sketch  does  little  justice  to  so 
remarkable  a  man.  Dr.  William  Hunt's  memoir  of  Leidy  is 
full  and  most  interesting,  and  should  be  read  by  all  who  can 
admire  the  genius  and  brilliancy  of  this  unassuming,  quiet, 
modest  gentleman,  who  died  when  the  world  needed  more 
than  ever  his  great  talents  and  indefatigable  industry. 

William  Hunt  was  Demonstrator  of  Anatomy.  No  better 
man  ever  lived  than  William  Hunt.  Bright,  genial,  pains- 
taking, and  industrious,  he  made  a  good  demonstrator  of 
anatomy  and  successfully  filled  the  position  for  a  number  of 
years.  He  was  a  good  practical  anatomist,  and  his  lectures 
on  surgical  anatomy  were  among  the  best  delivered  in  Phila- 
delphia in  his  day.  He  was  made  surgeon  at  the  Pennsylva- 
nia Hospital  in  the  early  part  of  his  career,  and  held  the  place 
up  to  the  time  of  his  death.  The  vast  material  available  at 
this  hospital  was  a  great  opportunity  for  any  man  in  surgery, 
and  Hunt  made  good  use  of  it.  He  was  conservative  and 
non-aggressive,  but  he  had  wonderfully  good  judgment,  and 
probably  no  one  was  better  ecjuipped  than  Hunt  for  passing 
upon  the  propriety  or  non-propriety  of  an  operation.  His 
nature  was  most  kindly,  and  he  was  always  ready  with  a  joke 
or  a  good  story  applicable  to  the  environment.  Among  his 
stories,  two  of  the  best  were  McMullen's  nose  and  the  stone 
case.  As  I  remember  the  stone  case,  when  he  was  first  made 
surgeon  at  the  Pennsylvania  Hospital  he  found  a  little  boy 
had  been  admitted  to  his  ward  who  had  stone  in  the  bladder. 
This  was  a  great  find,  as  stone  cases  were  considered  in  those 
days  among  the  most  desirable  for  a  show  clinic.  Hunt  had 
arranged  to  operate  on  the  coming  Saturday.  About  the  time 
the  patient  was  ready  for  the  ether  previous  to  being  taken 
into  the  amphitheatre,  the  father  appeared  and  asked  for  an 
interview  with  the  surgeon.    "  Now,  doctor,  you  are  a  young- 

40 


FORTY    YEARS    IN    'IMfK    MI':I)IC:AL    PROF-ICSSION 

looking-  man.  Did  you  ever  in  your  life  do  an  operation  of 
this  kind?"  Hunt  said  he  was  completely  taken  aback,  but 
soon  recovered  himself  and  promptly  answered,  "  No;  but  1 
consider  myself  entirely  f|ualified  to  do  the  operation,  and 
promise  to  do  all  in  my  power  to  help  your  boy."  The  father 
answered,  "  Well,  doctor,  I  think  I  will  take  him  to  an  older 
man."  And  then  and  there  he  made  preparation  to  remove 
the  lad  from  the  institution,  and  did  so.  Hunt  went  before 
the  class  and  unreservedly  told  the  whole  story  as  it  had  hap- 
pened, adding-,  in  his  droll  manner,  "  Gentlemen,  I  would  not 
tell  a  lie,  no,  not  even  for  a  stone  case."  Personally  I  was 
greatly  attached  to  Dr.  Hunt;  he  was  one  of  my  preceptors 
and  a  good  and  kind  friend  in  my  early  life ;  and  it  is  a  mel- 
ancholy pleasure  to  me  to  drop  a  tear  upon  his  tomb  and  place 
a  fragrant  flower  upon  his  grave. 

D.  Hayes  Agnew  succeeded  Dr.  Hunt  as  Demonstrator  of 
Anatomy  at  the  University.  Every  one  knows  who  Dr. 
Agnew  was, — one  of  the  grandest  of  men  and  one  of  the 
greatest  of  surgeons.  As  a  practical  anatomist  he  had  no 
superior,  and  as  a  teacher  of  anatomy  he  was  wonderfully  apt 
and  successful.  Being  botli  anatomist  and  surgeon,  he  made 
his  lectures  inviting  on  vvdiat  students  have  generally  consid- 
ered dry  matter,  by  bringing  in  regional  and  applied  anatomy, 
and  his  school  in  the  rickety  old  building  on  what  is  now 
Ludlow  Street,  back  of  where  the  old  University  stood,  is 
well  remembered  by  many  men  still  living  who  were  fortunate 
enough  to  get  the  benefit  of  his  teachings.  Agnew  took  a 
great  interest  in  young  men,  and  was  as  kind  and  afifable  to 
the  tyro  as  to  the  veteran  in  the  profession,  and  he  carried 
this  kindly  manner  and  affability  into  his  professional  life  as 
a  consultant,  and  greatly  to  these  kindly  traits,  strengthened, 
of  course,  by  his  surpassing  ability  as  a  surgeon,  did  he  owe 
the  fact  of  his  enormous  consultation  practice,  extending  to  a 
majority  of  such  cases,  perhaps,  happening  at  the  height  of 
his  busy  life,  in  the  States  of  Pennsylvania,  New  Jersey,  and 
Delaware.  No  thought  or  look  ever  escaped  him  which  could 
be  construed  as  an  effort  to  deteriorate  a  professional  brother 

41 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

in  a  case  with  him.  He  always  left  his  co-consultant  with  the 
feeling-  that  he  was  his  equal,  and  every  man  who  had  him 
once  wanted  him  again.  All  great  surgeons  do  not  act  as 
Agnew  did,  either  towards  students  or  towards  those  who  call 
them  in  as  advisers,  and  such  men  sooner  or  later  suffer  both 
in  lack  of  clients  and  admirers.  Agnew  was  a  constant  and 
unceasing  worker,  from  the  time  he  came  from  his  vocation 
as  a  country  practitioner,  all  through  the  days  of  his  obscu- 
rity in  his  dingy  dissecting  garrets  in  the  city,  up  to  almost 
the  very  hour  of  his  death.  His  literary  work  will  long  re- 
main a  monument  to  his  memory,  both  in  his  great  volumes 
on  surgery  and  in  his  other  books  and  monographs.  He  took 
little  recreation,  and  was  little  versed  in  the  ways  and  frivoli- 
ties of  the  world.  He  was  in  religion  a  zealous  Presbyterian, 
and  in  the  church  he  found  his  amusement  and  relaxation 
from  his  weary  toil,  rather  than  in  social  pleasures.  I  doubt 
if  he  even  went  to  the  theatre,  possibly  had  never  even  seen  a 
circus.  He,  indeed,  knew  nothing  but  work.  Thousands  got 
the  benefit  of  his  self-denial,  and  when  he  died  the  world  lost 
one  of  its  grandest,  greatest,  and  best  of  men. 

There  were  several  quiz  classes  at  the  University  during 
the  later  days  of  its  Ninth  Street  existence  which  did  good 
work  for  the  students,  and  were  particularly  of  advantage, 
for  a  majority  rushed  through  in  the  two  years'  course  then 
allowable  rather  than  take  the  three  years'  term.  Many  men 
doubtless  made  their  final  examinations  successful  only  by 
aid  of  the  quiz,  and,  besides,  the  quiz  masters  were  nearer  the 
students  than  the  professors,  and  gave  them  a  feeling  of  con- 
fidence, a  feeling  that  they  had  some  friend  to  turn  to  in  their 
hour  of  trial.  Morris,  Boiling,  and  Darby  had  a  large  quiz 
in  rooms  at  Ninth  and  Chestnut  Streets,  which  afterwards 
became  Morris,  Boiling,  and  Hodge,  and  later.  Boiling,  Hutch- 
inson, and  Hodge.  Levick,  Hunt,  and  Penrose  had  a  large 
and  most  successful  quiz  down  Jayne  Street  below  Ninth, 
opposite  the  entrance  to  the  Medical  Department,  and  back 
of  Baity  Sower's  well-known  saloon.  The  late  Dr.  Bishop,  a 
genial  good  man,  and  the  late  eminent  Joseph  Janvier  Wood- 

42 


FORTY    YEARS    IN    'rillC    MIODJCAL    I'J<()J' ICSSION 

ward,  who  did  such  good  work  in  the  mcchcal  history  of  the 
late  Civil  War,  had  also  a  large  (jiiiz  class.  The  present  emi- 
nent University  ])rofessors,  Tyson  and  Wood,  with  the  late 
Professor  Pepper,  had  a  very  successful  class,  and  another 
was  Black,  Boardman,  and  Woods. 

Janitor  Price  was  a  genial  man,  who  took  charge  of  the 
matriculating  hooks  and  gave  advice  to  the  students  from  a 
distance  in  the  little  office  to  the  right  of  the  general  entrance, 
and  was  afterwards  succeeded  hy  William  Salvador,  who  was 
promoted  from  the  charge  of  the  surgical  ward  connected 
with  the  surgical  clinic.  Salvador  is  still  connected  with  the 
University. 

Old  John  Brown,  good  old  John  Brown,  was  a  kindly  old 
man  in  charge  of  the  rooms  and  belongings  of  the  Professor 
of  Surgery,  and  janitor  of  the  bandaging-room.  The  noto- 
riety attaching  to  John  was  the  long  time  he  had  been  con- 
nected with  the  University  Medical  School.  At  that  time, 
1863,  he  had  been  there,  I  think,  about  fifty  years,  having 
served  Professors  Smith,  Gibson,  and  probably  far  into  the 
time  of  Physick. 

Of  all  the  minor  characters  about  the  University,  Nash, 
the  janitor  of  the  dissecting-rooms,  was  probably  the  most 
unique  and  the  longest  to  be  remembered.  Imagine  a  very 
tall,  lanky  man,  with  arms  too  long  for  his  body,  with  a  halt 
in  his  gait  which  compelled  him  to  drag  his  limb,  giving  him 
a  compound  gait,  a  gait  between  that  of  a  Jackey  just  ashore 
from  a  long  cruise,  and  constantly  hitching  up  his  trousers, 
and  that  of  a  man  learning  to  walk  with  an  artificial  limb 
above  the  knee.  Nash  had  all  these  movements  in  his  walk : 
he  jerked  up  behind,  described  an  outward  semicircle,  and 
then  planted  his  foot  with  a  flop  at  each  step.  He  was  pock- 
marked, had  a  small,  restless  gray  eye,  a  voice  with  a  squeak 
and  a  wheeze  which  appeared  to  come  from  his  boots.  He 
had  an  intimate  acquaintance  with  all  the  dealers  in  subjects 
within  many  miles  of  Philadelphia,  was  well  up  in  preparing 
them  for  dissection,  always  abused  the  hospital  doctors  as 
being  the  cause,  through  their  post-mortems,  of  the  non-suc- 

43 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

eess  of  his  arterial  injections, — and,  as  a  rule,  these  never 
were  successful  with  him, — got  up  skeletons  for  sale  to  the 
students,  mixing  his  cuneiforms  and  pisiforms  in  a  way.  as 
Hunt  once  said,  sure  to  cause  trouble  when  the  great  reckon- 
ing to  all  men  should  come,  was  fond  of  rum,  cursed  like  an 
army  corporal,  swore  by  Dr.  Leidy,  and  looked  like  the  devil, 
as  imagined  by  man.     Peace  to  his  ashes. 

There  was  another  character  about  the  University  at  that 
time,  a  student  from  North  Carolina  or  one  of  the  Southern 
States,  who  to  me  is  rather  a  memory  than  a  reality,  and 
whose  name  I  have  forgotten.  He  was  a  true  wit  and  a  wily, 
mischievous  wag,  up  to  all  kinds  of  pranks,  and,  withal,  a 
good  student  and  a  jolly  good  fellow.  He  left  his  name  em- 
balmed in  the  University  as  the  author  of  the  Turpentine  song. 
Through  the  works  and  suggestions  of  that  eminent  profes- 
sor, George  B.  Wood,  the  oil  of  turpentine  was  looked  upon 
as  a  sovereign  remedy  in  many  ailments  of  mankind,  and  the 
luckless  being  in  those  days  with  typhoid  fever  who  escaped 
a  turpentine  julep  every  few  hours  might  be  looked  upon  as  a 
freak  in  nature.  I  wish  I  had  a  copy  of  the  song.  I  don't 
know  that  it  is  in  existence.  It  referred  to  some  unfortunate 
imaginary  girl  in  a  paroxysm  of  hysteria.  All  I  remember  is 
the  refrain, — 

"  Turpentine,  Turpentine, 
We  poured  cold  water  down  her  spine; 
We  gave  her  oil  of  turpentine; 
Turpentine,  Turpentine." 

With  emphasis  and  high  inflection  on  the  "  tine"  in  the  last 
line. 

The  little  lecture-room  on  Ludlow  Street  back  of  St.  Ste- 
phen's Church  was  a  favorite  lecture-room  for  many  men 
who  had  been,  and  are  now,  prominent  in  medicine  in  Phila- 
delphia. Dr.  R.  A.  F,  Penrose,  Emeritus  Professor  of  Ob- 
stetrics and  Diseases  of  Women  and  Children  in  the  Uni- 
versity, delivered  his  well-attended  and  popular  courses  of 
lectures  there  as  an  adjunct  course  to  the  regular  University 
course.     These  lectures  continued  each  winter  until  Dr.  Pen- 

44 


FORTY    YEARS    IN    TIIIC    MEDICAL    PROFESSION 

rose  was  elected  to  succeed  Dr.  Hodge.  Penrose  was  doubt- 
less the  best  teacher  of  his  day  of  the  art  of  obstetrics.  None 
who  ever  heard  him  will  ever  forget  his  (Ad  friend  Mrs. 
O'Flaherty  and  the  lifelike  demonstrations  he  gave  with  her 
as  subject.  Mrs.  O'Flaherty  under  Penrose's  faithful  care 
and  assistance  probably  had  more  children  than  any  other 
woman  who  ever  lived,  and  every  conceivable  operation  that 
could  be  performed  upon  a  lying-in  woman  did  Mrs.  O'Fla- 
herty undergo  time  and  again.  She  served  her  day  and  gen- 
eration well,  and  many  of  her  sex  owe  her  a  debt  of  gratitude 
for  the  help  she  gave  in  the  education  of  many  of  the  great 
obstetricians  of  the  present  time.  The  obstetrical  hat  was 
another  inseparable  part  of  the  equipment  of  Penrose's  school. 
Now  and  again  an  advanced  student  was  given  a  case  to  at- 
tend in  the  poor  district.  On  these  occasions  the  wearing  of 
the  obstetrical  hat  was  compulsory,  for  no  woman  would 
respect  any  doctor  in  those  days  under  such  conditions  wdio 
did  not  wear  a  high  hat.  Dr.  Penrose  still  lives,  retired,  en- 
joying a  well-earned  rest,  respected  and  admired  by  the  thou- 
sands he  has  served  so  well  both  as  teacher  and  physician. 

In  the  same  little  lecture-room  Dr.  S.  Weir  Mitchell  now^ 
and  again  gave  a  lecture  on  some  subject,  generally  connected 
with  physiology  in  an  experimental  way,  and  it  is  only  neces- 
sary to  say  that  Mitchell  gave  a  lecture,  to  say  that  it  was 
bright,  educating,  and  entertaining.  At  that  time  he  was 
carrying  on  his  great  work  on  snake-poisons,  and  these  mat- 
ters were  the  subjects  of  some  of  his  lectures.  Fortunately 
for  the  world,  this  brilliant  man  still  lives,  physician,  novelist, 
and  poet,  his  work  ever  enduring,  his  talents  ever  increasing. 
May  he  continue  to  live  many  years,  and  pass  the  evening  of 
his  life  as  becomes  the  accomplished  and  cultivated  gentleman 
that  he  is.  Before  leaving  the  University  it  may  be  well  to 
take  a  survey  of  the  course  of  lectures  delivered  there,  and 
the  work  done  by  the  students  previous  to  applying  for  their 
degree,  and  compare  it  somewhat  with  the  work  now  done  in 
the  same  institution  by  men  before  they  take  their  degree.  I 
think  this  will  show  the  great  changes  that  have  taken  place 

45 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

in  medical  education  and  the  great  advantages  men  of  the 
present  day  have  over  those  of  forty  years  ago.  Compare 
these  changes  with  the  advances  in  practice,  and  they  only 
show  that  one  has  necessarily  kept  pace  with  the  other.  Com- 
pare the  changes  and  advances  in  both  medical  education  and 
medical  practice  with  the  changes  and  advances  in  all  matters 
pertaining  to  human  change  and  human  progress,  and  it  only 
shows  the  great  advancement  of  all  things  towards  a  higher 
civilization, — the  evolution  of  man  towards  the  perfect  type. 
The  completion  of  a  two  years'  course  allowed  a  student  to 
present  himself  for  graduation,  and  very  few  were  they  who 
did  not  accept  the  opportunity,  it  having  been  taken  for 
granted  that  they  had  been  studying  medicine  in  all  for  three 
years. 

The  following  may  be  taken  as  a  typical  day  of  routine  at 
the  school:  Nine  o'clock  a.m.,  quiz  class;  ten  a.m.,  lecture 
by  the  professor  of  chemistry;  eleven  a.m.,  lecture  by  the 
professor  of  anatomy;  twelve  m.,  lecture  by  the  professor  of 
practice;  one  p.m.,  lecture  by  the  professor  of  surgery;  three 
P.M.,  lecture  by  the  professor  of  materia  medica;  four  p.m., 
lecture  by  the  professor  of  obstetrics;  seven  p.m.,  lecture  by 
the  demonstrator  of  anatoni)^;  eight  to  ten  p.m.,  dissecting 
or  practical  surgery.  There  were  also  dispensary  clinics  held 
several  hours  each  week  in  the  University  Dispensary  De- 
partment which  students  were  invited  to  attend.  Wednes- 
days and  Saturdays  were  clinic  days  at  the  University  and  at 
the  hospitals, — ten  a.m.  to  twelve  m.  at  the  hospitals,  and 
from  twelve  m.  to  two  p.m.  at  the  University,  one  hour  each 
of  medicine  and  surgery,  respectively.  These  duties,  together 
with  a  few  outside  lectures  on  anatomy  and  obstetrics,  com- 
prised the  whole  course,  and  well  it  did,  for  the  students  were 
pressed  almost  beyond  endurance  if  they  worked  and  were 
conscientious.  The  fault  was  with  the  system,  the  cramming 
system,  and  the  course  too  short  even  for  that.  There  was 
no  practical  work  in  chemistry,  none  in  histology;  pathology 
was  taken  little  thought  of,  and  I  don't  remember  even  once 
looking  through  a  microscope  as  a  part  of  my  course  at  the 

46 


FORTY    YEARS    IN    T[IIL    MEDICAL    PROFESSION 

University;  all  of  this  iKjtwithstanding  the  work  then  re- 
cently (lone  by  Virchow  in  pathological  anatomy  and  the  whis- 
perings of  the  cell  doctrine,  the  onmis  cellula  e  cellula  oi  this 
wonderful  man. 

Turn  to  the  course  of  studies  for  the  degree  of  Medicine 
to-day  and  see  the  change.  It  is  apparent  at  once  what  makes 
this  change  possible, — the  compulsory  course  of  four  years, 
and  this  is  scarcely  sufficient.  The  classes  are  divided  into 
sections,  and  the  mere  didactic  lectures  in  the  general  course 
are  fast  becoming  the  least  essential  part  of  the  curriculum. 
The  dissecting  and  practical  surgery  classes  are  carried  on 
about  as  in  the  olden  times.  The  dissecting  done  by  students 
even  at  this  day  is  sufficient  to  give  them  a  practical  insight 
into  the  rudiments  of  the  work  only.  To  become  a  good 
practical  anatomist,  a  man  must  pass  many  midnight  hours 
over  the  cadaver  after  he  has  passed  from  the  halls  of  his 
alma  mater. 

To-day  the  student  takes  up  in  their  order,  with  a  fair 
amount  of  time  devoted  to  each,  and  with  special  instructors, 
practical  chemistry,  practical  biology,  general  pathology,  nor- 
mal histology,  practical  pharmacy,  practical  physiology, 
demonstrations  in  morbid  anatomy,  autopsies,  bedside  teach- 
ing, with  practical  work  in  dermatology,  obstetrics,  and  such 
like  work.  A  man  coming  out  who  has  faithfully  followed 
his  work  and  taken  proper  advantage  of  such  a  course  should 
at  least  be  in  condition  to  commence  to  learn  to  be  a  doctor. 


47 


CHAPTER    III. 

The  Jefferson  Medical  College,  Philadelphia — The  Faculty — Joseph  Pan- 
coast  and  James  Syme — S.  D.  Gross — The  Tone  of  the  Profession  in 
Philadelphia — Clinics — Hip-Joint  Cases — Clinical  Lecturers  in  Phila- 
delphia— The  Atlees  and  other  Great  Men — Professional  Methods — 
Trained  Nurses — The  Philadelphia  Hospital,  Blockley,  in  the  Early 
Sixties — Typhus  Fever. 

Four  decades  ago  the  Jefferson  Medical  College  in  Phila- 
delphia had  a  larger  class  than  the  University,  and  a  faculty 
not  surpassed  in  ability  by  any  in  the  country.  Such  great 
men  as  Charles  D.  Meigs,  Franklin  Bache,  John  K.  Mitchell, 
Robley  Dunglison,  Thomas  D.  Mutter,  and  others  had  about 
closed  their  long  services  to  the  institution,  and  had  been  suc- 
ceeded by  Samuel  D.  Gross,  Ellerslie  Wallace,  J.  Aitken 
Meigs,  and  S.  Henry  Dickson.  The  two  great  and  shining 
stars  of  this  faculty  were  Joseph  Pancoast  and  Samuel  D. 
Gross.  The  former,  professor  of  anatomy,  and  the  latter  of 
surgery.  Pancoast  was  a  thorough  practical  anatomist,  his 
knowledge  gained  from  hard  unceasing  practical  work.  As 
a  practical  surgeon  he  was  undoubtedly  one  of  the  greatest 
that  ever  lived.  At  that  day  he  had  an  enormous  and  lucra- 
tive practice,  and  did  most  of  the  consultation  work  in  the 
States  of  Pennsylvania,  New  Jersey,  and  Delaware,  just  as 
Agnew  did  at  a  later  day.  Pancoast  was  a  large,  thick-set 
man,  with  a  good  deal  of  manner,  a  kindly  manner,  which  at 
times  appeared  forced.  His  hand,  that  organ  which  did  so 
much  for  him  and  for  humanity,  was  large,  heavy,  and  thick, 
with  immense  blunt  fingers;  any  other  than  a  hand  you 
would  look  upon  as  facile  and  dexterous  almost  beyond  belief. 
The  facility  with  which  he  cut  for  stone  was  a  revelation.  He 
was  fond  of  the  bilateral  operation  in  proper  cases,  and  he 
was  unapproachable  in  this  method.     He  could  do  a  robust 


FORTY    YEARS    IN    THE    MEI>ICAL    PROFESSION 

Operation,  as  a  hip-joint,  and  pass  with  j^raccful  case  t(j  a  case 
of  cataract  and  remove  tiie  lens  witli  all  the  skill  and  confi- 
dence of  a  Bowman.  It  was  in  practical  work  as  a  surgeon 
that  Pancoast  excelled.  It  was  wonderful  how  he  could  use 
those  great  blunt  fingers.  They  appeared  to  take  on  any  shape 
he  chose  to  give  them ;  they  could  turn  and  twist  and  reach 
anywhere.  He  had  a  telescopic  eye,  the  artistic  touch  of  a 
Levis,  the  precision  and  confidence  of  an  Agnew,  with  all  the 
grace  and  rapidity  of  a  Morton.  He  had  all  these  gifts  and 
even  more.  He  did  little  on  the  literary  side  of  the  profes- 
sion. He  was  an  impressive-looking  man,  and  had  a  very 
impressive  manner  in  clinic.  His  audience  was  always  en 
rapport  with  the  man,  and  his  patients  looked  upon  him  as 
next  to  divine.  Should  I  be  asked  to  name  the  two  greatest 
operating  surgeons  of  that  day,  I  think,  without  deteriorating 
others,  I  should  name  Joseph  Pancoast,  of  Philadelphia,  and 
James  Syme,  of  Edinburgh.  Should  I  be  asked  to  name  the 
one  greatest,  I  should  name  Joseph  Pancoast,  of  Philadelphia. 
The  mention  of  Pancoast's  name  naturally  brings  up  the 
name  of  his  great  colleague  Gross.  Samuel  David  Gross  was 
the  Professor  of  Surgery,  and  was  an  emperor  among  men. 
He  would  have  been  a  great  man  in  any  calling,  and  nothing 
I  can  say  here  can  add  to  his  fame,  for  I  doubt  if  any  name 
in  the  profession  has  had  more  written  about  it  in  laudation 
than  the  name  of  Samuel  D.  Gross.  I  knew  him  well,  was  his 
resident  at  Blockley,  have  seen  him  under  many  conditions 
and  under  many  circumstances,  and  under  all  these  conditions 
and  under  all  these  circumstances  he  was  the  same  great  man. 
Gross's  methods  were  in  advance  of  the  methods  of  the  day 
in  many  matters.  Before  an  amputation  he  always  made  us 
raise  the  limb  and  drain  the  superficial  veins  by  rubbing,  and 
then  would  apply  a  bandage,  much  the  method  used  by  Es- 
march  at  a  later  day,  and  onl}'  lacking  the  elastic  bandage, 
the  ordinary  tourniquet  taking  the  place  of  Esmarch's  elastic 
one.  I  think  he  paid  more  attention  to  cleanliness  in  his  dress- 
ings than  most  of  the  surgeons  at  that  time,  and  insisted  on  a 
nearer  aseptic  condition  than  others,  far  as  it  was  removed 
4  49 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

from  the  asepsis  demanded  to-day.  He  also  paid  more  atten- 
tion to  drainage  of  wounds  than  did  most  of  his  colleagues. 
As  a  diagnostician  he  was  very  correct,  and  his  vast  store  of 
experience  served  him  well  in  this  direction.  As  a  writer  and 
author  he  was  one  of  the  greatest  the  profession  has  ever  pro- 
duced, and  his  great  work  on  general  surgery  will  ever  stand 
as  a  monument  to  his  memory.  In  personal  appearance  Gross 
was  an  imposing-looking  man,  and  from  pictures  handed 
down  to  us  I  should  imagine  there  was  a  strong  resemblance 
in  him  to  the  great  John  Hunter,  his  great  admiration,  and 
whose  biographer  he  was.  In  pathology  Gross  was  far  ahead 
of  most  of  his  contemporaries.  All  were  fearfully  lacking 
as  compared  with  our  modern  workers,  but  Gross  was  a 
leader,  a  close  student  of  pathology,  as  well  as  a  writer  and 
teacher. 

Robley  Dunglison  was  a  remarkable  man  and  filled  the 
chair  of  Physiology  with  ability.  As  an  author  he  is  well 
known,  and  in  his  great  work,  Dunglison's  Medical  Diction- 
ary, has  left  a  legacy  to  the  profession  which  makes  it  greatly 
his  debtor.  J.  Aitken  Meigs,  his  successor,  long  since  de- 
ceased, was  a  painstaking  man,  and  had  a  world-wide  reputa- 
tion for  his  special  work. 

Dr.  Ellerslie  Wallace  served  acceptably  in  the  chair  of 
Obstetrics,  and  often  in  his  lectures  gave  vivid  pictures  of  the 
accidents  that  may  come  to  us  in  obstetric  practice. 

John  Barclay  Biddle,  about  1865,  was  made  Professor  of 
Materia  Medica  and  Therapeutics,  served  the  school  success- 
fully for  a  number  of  years,  and  was  noted  as  an  author  of 
text-books  of  much  merit. 

I  have  always  been  an  admirer  of  the  high  tone  of  the  pro- 
fession of  medicine  in  Philadelphia.  I  have  travelled  a  good 
deal  over  the  world,  I  have  observed  the  profession  critically 
in  many  places,  and  in  no  country,  in  no  city,  in  no  town, 
have  I  ever  found  more  true  gentlemanly  courtesy  between 
doctors,  more  true  genuine  ability  in  the  ranks  of  the  profes- 
sion, or  a  higher  tone  in  all  matters  germane  to  the  great 
calling  we  have  the  honor  to  follow. 

so 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

The  great  hospital  clinics  of  the  decade  between  i860  and 
1870  were  held  at  the  Pennsylvania  Hospital,  at  the  i'hila- 
delphia  Hospital,  Blockley,  and  at  the  University  and  Jeffer- 
son schools.  At  the  University  Henry  H.  Smith  held  the 
surgical  clinic,  and  William  Pepper,  Sr.,  the  medical  clinic. 
At  the  Jefferson,  Gross  and  Pancoast  held  the  surgical  clinic, 
of  course,  and  Dickson  the  medical.  At  the  Pennsylvania 
Hospital  there  were  many  bright  men  and  good  teachers. 
There  were  Pancoast,  George  W.  Norris,  William  Hunt, 
Thomas  G.  Morton,  and  Agnew  as  surgeons;  W.  W.  Ger- 
hard, J.  Forsyth  Meigs,  Da  Costa,  Levick,  and  others  in 
medicine.  At  Blockley  there  were  Samuel  D.  Gross,  Agnew, 
Levis,  Maury,  Lodge,  Kenderdine,  and  others  in  surgery; 
Da  Costa,  Tutt,  Zeigler,  and  others  in  medicine ;  and  R.  A.  F, 
Penrose  and  Duer  in  o1)stetrics. 

The  great  operations  for  show  clinics  of  that  day  were 
stone  in  the  bladder,  the  tying  of  the  larger  blood-vessels, 
amputation  at  the  hip- joint,  and  tumors.  I  remember  well 
three  amputations  at  the  hip-joint  by  the  three  great  sur- 
geons, Joseph  Pancoast,  Samuel  D.  Gross,  and  D.  Hayes 
Agnew.  Pancoast's  was  the  first  case,  that  of  a  middle-aged 
woman  for  a  sarcomatous  growth  of  the  thigh.  It  took 
place  in  the  amphitheatre  of  the  Jefferson  clinic.  There  was 
a  large  audience  present  of  physicians  and  students,  and  S. 
D.  Gross  assisted  at  the  operation.  The  whole  scene  was 
dramatic.  Both  Gross  and  Pancoast  had  something  to  say. 
Pancoast's  address  was  quite  pathetic:  he  spoke  of  the  poor 
woman,  the  gravity  of  the  operation  and  its  uncertain  ending 
for  the  patient,  said  she  had  seen  her  clergyman,  had  had  the 
last  rites  of  her  church,  and  trusted  herself  to  her  surgeon 
and  to  her  God.  After  the  ether  had  been  administered, 
which  was  done  after  the  preliminary  examination  and  ex- 
planation of  the  case  had  been  gone  through  with,  the  abdomi- 
nal tourniquet  was  applied  by  Pancoast  himself.  He  spoke 
of  its  uses,  and  said,  "  Gentlemen,  there  zvill  be  no  hemor- 
rhage." He  then  took  his  place,  with  nothing  but  a  large 
scalpel  in  his  hand.     Gross  stood  by  him,  and  Maury  had 

51 


FORTY   YEARS    IN   THE    MEDICAL    PROFESSION 

charge  of  the  limb.  "  Now,  gentlemen,  are  we  all  ready? 
Maury,  you  are  a  good  fellow.  I  depend  on  you;  when  I 
say  lift,  you  lift;  when  I  say  lower,  you  lower;  when  I  say 
right,  move  the  limb  to  the  right;  and  left,  move  to  the  left." 
He  commenced  by  making  first  an  anterior  skin-flap,  then  a 
similar  posterior  one,  then  a  circular  of  the  muscles,  com- 
pleting the  operation  by  dislodging  the  head  of  the  femur, 
without  once  stopping  or  laying  down  the  knife.  There  was 
no  bleeding,  and  the  securing  of  the  vessels  and  the  dressings 
completed  the  brilliant  operation.  The  patient  made  a  good 
and  rapid  recovery. 

Not  long  after  Pancoast's  operation.  Gross  had  a  similar 
one  in  the  same  amphitheatre.  This  case  was  a  man  with  a 
sarcoma  of  the  thigh  of  rapid  growth.  It  was  near  the  open- 
ing of  the  session,  and  was  made  a  grand  occasion  to  give 
eclat  to  the  school.  Pancoast  was  there,  grand  and  imposing. 
He  said,  "  Gentlemen,  Professor  Gross  is  the  hero  of  this 
occasion,  but  while  he  is  arranging  his  preliminaries  I  will 
do  a  little  operation  to  put  in  the  time."  He  then  removed  a 
tumor  from  the  parotid  region  in  a  man,  and  did  it  gracefully, 
rapidly,  and  successfully.  Then  came  Gross's  turn.  His  case 
was  that  of  a  man  of  middle  age,  with  good  antecedents. 
Pancoast  was  near,  and  his  regular  assistant,  Maury.  Gross 
ordered  the  limb  raised  at  right  angles  with  the  body.  Then 
he  massaged  the  limb  to  drain  it  of  its  blood,  then  had  it 
bandaged  as  high  as  possible,  not  to  interfere  with  his  work. 
He  then,  with  Pancoast's  assistance,  applied  the  abdominal 
tourniquet.  He  next  took  up  a  large  scalpel  and  made,  first, 
an  anterior  skin-flap,  then  a  posterior  one;  next  he  dropped 
the  scalpel  and  took  up  a  catling  of  medium  size,  made  short 
anterior  and  posterior  flaps  of  the  muscles,  and  completed 
the  operation  by  disarticulating  the  head  of  the  bone  with  the 
same  knife.  There  was  no  hemorrhage.  These  two  cases 
show  the  great  success  of  the  abdominal  tourniquet,  with  no 
after  ill  effect.  The  vessels  were  soon  tied  off,  the  flaps 
stitched,  with  the  additional  support  of  a  long  needle,  proba- 
bly five  inches  long,  run  through,  then  across  several  inches, 

52 


FORTY    YEARS    IN    TITE    MEDICAL    PROFESSION 

and  through  again.  The  (h-cssings  and  bandages  completed 
the  operation,  most  beautifully  and  thoroughly  done, 

I  saw  something  of  the  after-treatment  of  this  case  with 
Maury.  There  were  no  soiled  towels  or  dressings  lying 
around,  I  assure  you,  when  the  old  gentleman  was  expected. 
The  man  made  a  good  recovery. 

The  next  case  was  Agnew's,  at  the  clinic  of  the  Pennsyl- 
vania Hospital.  I  think  Pancoast  was  in  Europe  then,  but 
Gross  and  many  of  the  other  surgeons  of  the  city  were  on 
hand.  This  case  was  an  elderly  man  who  had  been  to  some 
extent  a  drinker.  His  vessels  were  somewhat  hardened, 
which  made  the  case  a  little  unpromising.  It  also  was  a  case 
of  sarcoma,  and  was  no  doubt  an  operable  one.  The  day 
before,  Agnew  had  laid  out  the  line  of  his  incisions  for  the 
flaps  by  tracing  them  with  a  dampened  stick  of  silver  nitrate 
on  the  skin.  He  had  the  limb  raised  at  right  angles  to  the 
body  and  massaged,  to  empty  the  vessels,  and  applied  a  band- 
age. This  was  particularly  well  here,  for  there  were  some 
varicose  veins  below  the  knee.  Next  he  applied  the  abdomi- 
nal tourniquet,  as  was  done  in  the  other  cases.  When  e\-ery- 
thing  was  ready,  he  took  a  large  scalpel  in  his  hand.  Agnew 
was  ambidextrous,  and  it  made  no  difference  to  him  which 
he  used.  He  made  his  skin-flaps  anteriorly  and  posteriorly, 
following  the  lines  already  laid  out.  These  finished,  he 
opened  the  sheath  of  the  femoral  vessels  and  tied  both  artery 
and  vein ;  then  with  a  catling  he  completed  the  operation  by 
making  short  anterior  and  posterior  ilaps  of  the  muscles,  and 
lastly  disarticulated  the  bone.  There  was  no  hemorrhage. 
The  operation  was  completed  by  tying  off  the  vessels  remain- 
ing, stitching  the  flaps,  and  applying  the  dressings.  The  man 
did  well  until  about  the  tenth  day,  when  he  died  of  secondary 
hemorrhage,  a  result  not  altogether  unlocked  for,  and  from 
no  fault  of  the  operator  either  during  the  operation  or  during 
the  after-treatment.  The  operation  was  beautifully  done, 
exhibiting  that  care  and  attention  to  detail  for  which  Agnew 
was  always  noted.  Two  out  of  three  cases  successful  was  a 
wonderful  record  in  those  days  before  asepsis  and  antisepsis 

53 


FORTY   YEARS    IN    THE    MEDICAL    PROFESSION 

were  thought  of.  They  were,  of  course,  secondary  cases, — 
that  is  to  say,  not  cases  requiring  amputation  for  primary 
injury.  Such  cases  are  very  different,  and  most  of  them  have 
died  from  shock  during  or  soon  after  the  operation.  There 
is  one  thought  comes  to  me  before  I  dismiss  Agnew's  case: 
Did  opening  up  the  sheath  of  the  femoral  vessels  and  tying  the 
vessels  before  completing  the  operation  tend  towards  pro- 
ducing the  secondary  hemorrhage?  Had  the  man's  blood- 
vessels been  sound,  he  probably  would  have  recovered,  but  I 
believe  it  better  to  control  the  hemorrhage  by  other  means 
than  by  preliminary  ligation. 

I  had  one  primary  case  with  my  friend,  the  late  Dr.  George 
Troup  Maxwell,  of  Florida, — a  little  boy,  from  a  railroad 
crush.  He  rallied  enough  and  lived  long  enough  to  demand 
action,  but  died  shortly  after  the  successful  operation.  I  have 
no  statistics  at  hand,  but  I  think  there  was  one  case  survived 
out  of  a  great  many  in  the  Crimean  War.  In  the  late  war  of 
the  Rebellion,  during  the  first  part  of  it,  a  number  died  after 
or  during  the  operation.  So  much  was  said  at  the  time  about 
these  operations  that  I  think  an  order  was  issued  forbidding 
them  on  the  field,  at  least.  Dr.  Edward  Shippen,  late  of  Phil- 
adelphia, later  on  in  the  war  did  one  primary  operation  at  the 
hip,  and  the  man  recovered,  notwithstanding  he  was  banged 
around  in  an  army  ambulance  for  hours,  if  not  for  days,  im- 
mediately succeeding  the  operation.  To-day,  thirty  and  more 
years  since  the  time  we  have  been  speaking  of,  with  all  the 
improvements  in  instruments,  in  technique,  with  our  knowl- 
edge of  asepsis  and  antisepsis,  and  other  advantages,  amputa- 
tions at  the  hip  in  secondary  cases  should  be,  and  are,  cases 
in  which  we  may,  in  a  majority  of  instances,  look  forward  to 
success,  and  in  primary  cases  the  chances  ought  to  be  de- 
cidedly more  hopeful  and  operation  in  more  of  these  cases 
justifiable,  provided  always,  the  loss  of  blood  has  not  been  too 
great  and  shock  has  sufficiently  subsided.  Wyeth's  method 
is  now  the  accepted  method  in  this  greatest  of  operations,  and 
with  the  control  of  hemorrhage,  and  the  rigid  practice  of 
asepsis,  the  mortality  must  materially  decrease. 

54 


FORTY    YEARS    IN    THE    M1<:DICAL    PROFESSION 

Alfred  Stille  succeeded  Dr.  Pepper  as  Professor  of  Prac- 
tice at  the  University.  He  is  a  most  accomplished  and  schol- 
arly man,  and  for  many  years  delivered  a  finished  and  able 
course  of  lectures,  both  didactic  and  clinical.  He  still  lives, 
enjoying  a  well-earned  ease  in  his  old  age,  greatly  respected 
both  as  a  citizen  and  as  a  physician. 

Among  the  clinical  lecturers  of  distinction  in  Philadelphia 
at  this  time  was  W.  W.  Gerhard.  In  diagnosis  of  diseases 
of  the  chest  he  probably  excelled  any  man  in  America,  and 
as  an  author  was  well  known  for  his  writings  on  this  special 
subject.  He  was  very  irritable  during  his  clinical  talks,  and 
treated  his  class  much  as  any  old  dominie  might  have  treated 
his  boys  in  school-rooms  of  the  olden  time.  Edward  Peace 
was  surgeon  to  the  Pennsylvania  Hospital,  and  did  some  skil- 
ful work,  among  other  cases  being  one  of  ligation  of  the  sub- 
clavian within  the  scaleni.  Being  a  man  of  means,  he  retired 
at  an  early  age  from  active  work.  The  brilliant  John  Rhea 
Barton  retired  early  under  the  same  conditions,  which  early 
giving  up  of  professional  work  caused  Gross  to  speak  of  him 
as  one  of  the  ablest  and  most  brilliant  of  surgeons,  yet  at  the 
same  time  one  of  the  worst. 

Paul  Beck  Goddard  did  little  teaching  in  his  later  days,  but 
he  was  one  of  the  ablest  and  most  scholarly  of  all  the  members 
of  the  profession  in  the  country.  It  was  said  at  one  time  of 
Goddard,  that  he  could  fill,  with  honor  to  himself  and  with 
special  benefit  to  the  class,  any  one  or  all  of  the  seven  profes- 
sorships which  then  comprised  the  course  of  our  medical 
schools.  That  is  to  say,  he  could  fill  the  chairs  of  Anatomy, 
Surgery,  Practice  of  Medicine,  Obstetrics,  Physiology,  Chem- 
istry, and  Materia  Medica,  and,  I  may  add,  be  Demonstrator 
of  Anatomy  too. 

Addinell  Hewson  was  surgeon  at  the  Pennsylvania  Hos- 
pital, was  a  good  clinical  teacher,  and  an  accomplished  sur- 
geon and  gentleman.  George  W.  Norris  was  a  surgeon  of 
great  attainments,  was  the  great  authority  on  fractures  of  his 
day,  and  lectured  regTilarly  at  the  hospital.  The  Pennsylva- 
nia Hospital  had  an  immense  amount  of  clinical  material  in 

55 


FORTY   YEARS    IN    THE    MEDICAL    PROFESSION 

fractures,  and  it  was  a  treat  to  have  Norris  take  up  this  sub- 
ject for  a  cHnic. 

I  have  ah"eady  spoken  of  WilHam  Hunt.  His  friend  and 
companion  Thomas  G.  Morton  still  lives,  having  served  as 
surgeon  of  this  hospital  for  more  than  thirty  years.  A  won- 
derful service  in  years,  and  what  an  experience  to  a  man ! 
what  a  mine  to  work !  Morton  has  not  failed  to  work  it.  He 
is  to-day  one  of  the  great  surgeons  of  the  world,  whose  bril- 
liancy, rapidity,  and  dash  are  excelled  by  none.  Oh,  for  a 
record  of  such  a  life  work !  such  a  record  as  Ian  Maclaren  or 
a  Conan  Doyle  would  write, — the  joys,  the  sorrows,  the 
struggles  for  life,  the  triumphs  and  the  disappointments,  the 
sunlight,  the  gloom,  the  pathos,  the  joy,  coming  and  going, 
day  and  night!  We  all  get  weary  of  the  heavy  work,  the 
heavy  scientific  literature  of  the  profession.  To  come  home 
weary,  possibly  irritated,  possibly  grieved,  to  sit  down  to 
such  a  character  as  Doctor  MacLure,  is  positive  rest  for 
mind  and  body  wearied  by  unceasing  toil;  and  what  a  rest 
would  it  be  to  peruse  at  such  times  a  record  of  over  thirty- 
four  years  of  a  surgeon's  experience  in  a  great  hospital,  told 
by  some  gifted  man ! 

John  Forsyth  Meigs  was  a  regular  lecturer  at  the  Penn- 
sylvania, a  son  of  the  great  obstetrician  Charles  D.  Meigs. 
John  Meigs,  as  he  was  always  spoken  of,  was  a  very  busy 
man;  in  fact,  much  of  the  time  overworked,  from  his  im- 
mense family  practice.  He  was  a  great  authority  on  chil- 
dren's diseases,  as  his  well-known  work  on  that  subject  attests. 
Ellwood  Wilson  was  his  friend  and  frequent  consultant  in 
private  practice,  with  an  enormous  obstetric  practice,  and  was 
a  man  of  great  skill,  had  abundant  success,  and,  like  Meigs, 
worked  nearly  to  the  day  he  died. 

William  H.  Pancoast  was  a  bright,  pleasant  man,  a  son  of 
the  great  surgeon,  who  at  times  lectured  acceptably  and  after- 
wards succeeded  to  his  father's  chair  of  Anatomy  in  the  Jef- 
ferson school ;  afterwards  resigning  this  chair  and  going  to 
the  Medico-Chirurgical  College,  where  he  was  actively  em- 
ployed until  he  died. 

56 


FORTY    YEARS    IN    Till':    MICDICAL    PROFKSSION 

Edward  Uartshornc  and  I  Icnry  Hartshorne  were  promi- 
nent in  the  profession  in  IMiiladcl])hia  at  this  time,  the  one  a 
surgeon  and  the  other  a  well-known  lecturer  and  author.  ]). 
Francis  Condie  was  also  known  favorahly  in  diseases  f)f  chil- 
dren, on  which  suhject  he  wrote  a  very  elahorate  work  and 
edited  Sir  Thomas  Watson's  "  Practice  of  Physic." 

Among  the  greatest  of  the  great  names  in  surgery  of  the 
early  period  of  forty  years  ago  is  that  of  Washington  L. 
Atlee,  a  worthy  follower  of  his  great  prototype,  Ephraim 
McDowell.  Atlee  was  one  of  the  great  pioneers  in  ovari- 
otomy when  he  was  struggling  to  give  the  operation  a  sub- 
stantial basis  on  which  to  stand  as  a  justifiable  proceeding. 
I  have  heard  the  operation  denounced  from  the  amphitheatre 
of  one  of  the  great  medical  schools  as  next  to  murder,  and 
the  man  who  performed  the  operation  as  little  less  than  mur- 
derer and  little  more  than  fiend.  Atlee  continued  on  in  his 
heroic  struggle,  exhibiting  all  the  attributes  of  a  great  and 
fearless  man,  working  to  the  very  day  of  his  death.  His 
death  was  pathetic,  but  worthy  of  the  great  man  he  was.  He 
knew  he  had  malignant  disease  of  the  stomach,  and  when 
scarcely  able  to  support  himself  he  left  his  home,  went  to  the 
house  of  a  patient  at  a  distance,  and  returning  to  his  home 
exhausted,  he  died. 

'■  Like  one  who  wraps  the  drapery  of  his  couch  about  him 
And  lies  down  to  pleasant  dreams." 

Equally  eminent  in  surgery  and  gynsecology  was  his  dis- 
tinguished brother,  John  Light  Atlee,  of  Lancaster.  One 
cannot  mention  the  name  of  either  of  these  two  great  men 
without  thinking  of  the  other.  The  Atlees  were  a  family  of 
doctors,  and  they  have  all  been  distinguished  men.  Walter 
Franklin  Atlee,  of  Philadelphia,  child  of  Lancaster's  great 
son,  still  lives,  a  worthy  successor  of  his  father  and  uncle. 
As  a  general  surgeon  he  has  been  eminently  successful,  and 
as  a  gyn?scologist.  in  the  days  wdien  it  required  all  the  force, 
all  the  strength,  and  all  the  powers  of  a  man  to  be  a  g}'njecolo- 
gist,  he  was  the  peer  of  any  of  them.     Until  time  shall  be  no 

57 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

more,  no  woman  should  pass  the  grave  of  an  Atlee  and  fail 
to  drop  a  tear  upon  his  tomb. 

Forty  years  ago  in  Philadelphia  there  were  few  specialists. 
In  the  eye,  Dr.  Isaac  Hays  and  Dr.  Littell  did  little  or  no 
other  work.  They  were  both  very  eminent  men  of  their  day, 
and  Dr.  Hays  was  a  very  scholarly  man  and  cultivated  gen- 
tleman, and  edited  until  his  death,  the,  at  that  day,  great 
American  medical  journal,  the  American  Journal  of  the  Medi- 
cal Sciences,  or,  as  it  was  always  better  known,  "  Hays's 
Journal."  All  the  general  surgeons  like  Pancoast,  Gross, 
Agnew,  Morton,  Hunt,  Levis,  and  others,  did  eye-work. 
Ezra  Dyer  came  to  Philadelphia,  fresh  from  Von  Grafe's 
clinic  in  Berlin,  and  soon  established  a  large  practice.  He 
was  followed  by  George  Strawbridge,  a  most  accomplished 
oculist  and  eye  surgeon,  still  doing  good  work.  Dr.  Charles 
H.  Burnett  left  the  Philadelphia  schools,  went  to  Europe,  and 
returned  to  Philadelphia,  where  he  has  since  worked  success- 
fully, and  is  to-day  one  of  the  world's  great  authorities  on  the 
human  ear. 

In  medicine,  few  of  the  contemporaries  of  the  elder  Pepper 
and  Stille  survive.  Da  Costa  is  probably  the  nestor,  a  great 
didactic  and  clinical  teacher,  a  most  accurate  diagnostician 
of  world-wide  fame.  May  he  live  many  years  to  enlighten 
the  profession  he  has  served  so  well  and  done  so  much  to 
adorn.  James  Tyson,  the  Professor  of  Clinical  Medicine  at 
the  University  of  Pennsylvania,  is  a  wonderfully  active  man 
in  the  profession,  both  as  teacher  and  practitioner,  and  so  is 
Horatio  C.  Wood,  the  Professor  of  Materia  Medica.  All  of 
these  men  have  done  great  and  creditable  literary  work,  and 
upon  their  shoulders  in  Philadelphia,  together  with  D.  F, 
Woods,  Woodbury,  I.  Minis  Hays,  Henry,  Stengle,  Taylor, 
Hare,  Starr,  Cleeman,  Ingham,  Daland,  Anders,  Chapman, 
Gittings,  Wistar,  James  C.  Wilson,  Arthur  V.  Meigs,  and 
Musser,  distinguished  authors  and  teachers,  Wallace,  Stryker, 
Hickman,  Cadwalader,  Cheston,  and  others  equally  well 
known,  have  fallen  the  mantles  of  Chapman,  Mitchell,  the 
Peppers,  and  other  renowned  men.     These  mantles  they  will 

58 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

worthily  wear  until  the  cycle  revolves  again,  and  others,  now 
unknown,  shall  fill  their  places;  and  so  the  cycle  will  revolve 
until  time  shall  be  no  more. 

John  Ashhurst  and  J.  William  White  now  stand,  by  reason 
of  age  and  ability,  with  Morton  and  Keen  and  Brinton  at  the 
head  of  the  list  of  surgeons.  Ashhurst  and  White  are  pro- 
fessors of  surgery  at  the  University,  and  Keen  and  Brinton  at 
the  Jefferson  school,  and  each  maintains  the  ancient  prestige 
of  these  two  great  colleges.  There  are  mafiy  bright  and  able 
surgeons,  younger  men,  in  the  city,  most  prominent  among 
whom  are  Henry  R.  Wharton,  teacher  and  author;  Allis, 
Packard,  Mears,  Roberts,  Simes,  Martin,  S.  Ashhurst,  Hearn, 
Deaver,  T.  S.  K.  Morton,  Porter,  Barton,  La  Place,  Willard, 
Dulles,  Harte,  Le  Conte,  and  McClellan,  distinguished  author 
and  teacher. 

Among  gynaecologists  are  Baldy,  author,  teacher,  finished 
diagnostician,  and  operator ;  C.  B.  Penrose,  at  the  head  of  his 
specialty  at  the  University;  Girvin,  Duer,  Price,  Montgom- 
ery, Shoemaker,  Hirst,  Professor  of  Obstetrics  at  the  Univer- 
sity; Davis,  of  the  Jefferson  school;  Noble,  Baer,  Woods, 
Kruser,  Ashton,  and  others  well  known. 

On  the  eye,  ear,  and  throat  are  Harlan,  Norris,  Oliver, 
Gould,  a  most  accomplished  man;  de  Schweinitz,  Cohen, 
Randall,  Stout,  Risley,  McClure,  and  many,  many  more.  Not 
long  ago  you  could  count  the  eye  men  on  the  fingers  of  one 
hand ;  now  they  are  very  numerous,  and  still  increasing,  and 
so  is  the  good  they  are  doing,  for  in  eye  troubles  great  ad- 
vances have  been  and  are  being  made.  Philadelphia  lost  two 
of  her  brightest  and  brainiest  men  when  Osier  and  Kelly 
went  to  Baltimore,  where  they  are  now  doing  great  work,  and 
with  Halsted,  Welch,  and  others  are  rapidly  establishing  at 
Johns  Hopkins  one  of  the  great  medical  centres  of  the  world. 

In  forty  years  the  knowledge  of  the  pathology^  of  and 
treatment  of  diseases  of  the  skin  in  America  has  made  great 
progress.  It  was  only  taught  casually  in  the  schools  until 
recent  times,  and  little  attention  was  given  to  cases,  even  in 
clinics;    in  fact,  I  don't  think  teacher  or  pupil  knew  much 

59 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

about  them.  During  and  after  the  war  of  the  RebelHon  skin 
troubles  increased  greatly  in  America,  and  are  now,  as  we 
all  know,  quite  common.  Dr.  L.  A.  Duhring  took  up  the 
subject  as  a  specialty  early  in  his  professional  life,  and  now 
has  a  world-wide  reputation.  Dr.  Arthur  Van  Harlingen 
and  Dr.  John  V.  Shoemaker  are  known  experts  in  this  spe- 
cialty, whilst  Dr.  Henry  W.  Stelwagon  is  particularly  well 
known  as  both  author  and  teacher.  In  nervous  diseases  there 
are  Mitchell,  father  and  son,  Sinkler,  Mills,  Chapin,  Dercum, 
Martin  W.  Barr,  Horatio  Wood,  J.  Madison  Taylor,  and 
others.  It  was  at  first  not  my  intention  to  speak  of  the  living 
in  these  articles,  but  among  so  many  distinguished  names  it  is 
impossible  to  forbear  mentioning  a  few. 

In  the  decade  between  i860  and  1870  the  hospitals  in  Phila- 
delphia were  sufficient  for  the  needs  of  the  people,  and  were 
well  conducted.  The  Pennsylvania  was  the  great  surgical 
institution,  and  probably  had  the  best  medical  wards.  Block- 
ley  was  a  great  obstetrical  and  venereal  school,  besides  having 
a  profusion  of  general  practice.  The  Episcopal  was  a  fine 
hospital,  and  so  was  St.  Joseph's.  Wills  Eye  Hospital  was 
devoted  especially  to  diseases  of  the  eye.  During  the  war  the 
government  established  a  number  of  large  hospitals  in  Phila- 
delphia for  sick  and  wounded  soldiers,  and  they  did  great  and 
good  work.  These  were  the  West  Philadelphia,  the  South 
Street,  Nicetown,  Fifth  and  Buttonwood,  Broad  and  Cherry, 
Turner's  Lane,  Chestnut  Hill,  and  the  United  States  Army 
Officers'  Hospital,  at  Camac's  Woods,  now  Eleventh  and 
Berks  Streets.  Everybody  took  an  interest  in  these  organiza- 
tions, and  among  the  surgeons  in  charge  the  names  of  Camac, 
Hopkinson,  Le  Conte,  S.  W.  Gross,  and  John  Neill,  one  of 
Philadelphia's  most  noted  anatomists  and  surgeons,  are  well 
remembered.  William  Camac,  M.D.,  did  a  great  work  in  this 
service.  He,  at  his  own  expense,  converted  the  old  family 
homestead  at  Camac's  Woods  into  a  delightful  home  and  hos- 
pital for  sick  and  wounded  officers,  and  through  the  many 
dark  days  of  the  war  worked  and  watched,  relieving  the  suf- 
fering of  the  many  unfortunates  there  committed  to  his  care. 

60 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

In  October,  1864,  1  was  elected  one  of  the  resident  physi- 
cians of  the  Philadelphia  Hospital,  Blockley.  1  had  been  in 
the  medical  corps  of  the  United  States  army  since  1862,  and 
was  glad  to  avail  myself  of  the  great  resources  of  Blockley 
for  clinical  experience.  This  hospital  was  the  refuge  for  the 
indigent  sick  and  indigents  generally  of  Philadelphia  City  and 
County.  There  were  about  three  thousand  patients  within 
the  walls,  six  hundred  being  on  the  insane  side,  an  entirely 
separate  department.  The  institution  was  governed  by  the 
Board  of  Guardians  of  the  Poor,  and  had  a  complete  organiza- 
tion, which  was  more  or  less  political,  but  at  that  time  was 
composed  of  very  good  men  and  free  from  the  scandals  that 
had  some  time  previously  clustered  around  it.  The  practice 
there  was  interesting,  and  I  soon  learned  one  fact, — that  the 
habitues  of  almshouses  and  prisons,  as  a  rule,  being  accus- 
tomed to  over-stimulation  in  all  of  its  phases,  withstand 
knock-out  doses  with  great  impunity,  and  the  dosage  com- 
mon among  these  classes  is  no  safe  criterion  for  dosage  in 
private  practice.  The  under  employees  were  taken  from  the 
inmates,  as  a  rule,  and  whilst  many  of  them  were  good  ser- 
vants, they  were,  as  a  class,  moral  imbeciles,  and  I  doubt  if 
the  employment  of  such  in  such  institutions  is  economical 
either  to  the  municipality  or  to  the  State.  Now,  since  the  in- 
troduction of  the  trained  nurse  into  the  profession,  a  wonder- 
ful change  for  the  better  has  come  to  such  places  as  Blockley, 
and  one  who  was  there  in  the  olden  time,  and  seeing  the  order, 
attention  to  detail,  and  perfect  discipline  of  the  corps  of  well- 
bred,  well-trained  women  ministering  to  the  unfortunate  sick 
there  to-day,  cannot  help  but  note  the  contrast  and  applaud 
the  modern  methods  and  modern  ideas. 

The  clinical  material  of  every  class  of  disease  available  at 
Blockley  was  enormous.  There  were  the  old  men's  wards, 
the  old  women's  wards,  the  children's  asylum  w'ith  its  wards 
for  the  sick,  the  men's  and  women's  medical  wards,  the  male 
and  female  surgical  wards,  the  male  and  female  venereal 
wards,  the  obstetrical  wards,  and  the  Department  for  the 
Insane.    There  were  generally  two  visiting  surgeons  on  duty, 

61 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

one  taking  the  surgical  and  the  other  the  venereal  wards. 
One  medical  man  was  generally  on  duty  at  a  time,  and  con- 
tinued for  three  months ;  and  so  in  the  obstetrical  wards.  Dr. 
S.  W.  Butler  had  charge  of  the  Insane  Department,  with  Dr. 
Sparks  as  assistant.  The  services  of  these  gentlemen  were 
continuous.  Outside  of  the  Department  for  the  Insane  there 
were  eight  resident  physicians,  so  arranged  that  four  new 
men  came  on  in  the  spring  and  four  in  the  autumn.  In  the 
venereal  wards  I  served  as  resident  to  Professor  Gross.  He 
took  great  interest  in  this  branch  of  the  profession,  and  was  a 
dualist  subject  to  conditions,  as  syphilographers  were  divided 
in  those  days.  His  distinguished  colleague  in  the  hospital, 
Agnew,  was  a  unicist,  but  I  thought  at  the  time  was  weaken- 
ing a  little  in  his  belief.  Dr.  Gross  was  a  strict  disciplinarian 
in  his  wards  and  clinics,  was  rather  fond  of  a  joke  at  the 
expense  of  his  patients,  and  when  the  old  gentleman  com- 
menced to  whistle  in  a  whisper  and  kick  an  unoffending  towel 
across  the  ward,  somebody  might  expect  to  hear  from  him  in 
an  emphatic  way.  He  was  always  most  dignified  and  cour- 
teous in  his  clinics,  a  gentleman  of  the  old  school  par  excel- 
lence, and  was  fond  of  making  his  residents  assume  respon- 
sibilities, as  for  example,  when  about  to  amputate  a  leg,  he 
would  often  give  the  tournicjuet  a  toss  to  one  side  and  call 
upon  one  of  us  to  hold  the  femoral  artery  with  the  thumb.  At 
such  times  he  did  rapid  work,  but  if  some  rebellious  vessel 
caused  delay  in  its  ligation  the  luckless  resident  at  the  femoral 
had  his  own  troubles,  I  assure  you.  As  a  recompense  and 
compliment,  after  the  operation  had  been  successfully  brought 
to  a  close,  the  old  gentleman,  drawing  himself  to  his  full 
height,  would  turn  to  the  class  and  say,  "  Gentlemen,  with 
competent  and  intelligent  assistants,  a  surgeon  can  do  almost 
anything."  In  the  surgical  wards  I  served  with  Agnew.  Oh, 
Agnew  was  a  lovely  man !  No  wonder  students  admired  him 
and  so  many  of  them  came  to  him  for  advice  in  their  profes- 
sional work.  I  have  seen  him  under  all  conditions, — in  his 
work  in  the  dissecting-room,  at  his  home,  in  his  hospital  work, 
in  his  clinic.    I  never  saw  him  ruffled  or  excited,  I  never  saw 

62 


FORTY    YI<:AK.S    IN    Till':    MI'.hlCAL    PROFESSION 

him  rude  to  the  most  menial  of  those  about  him,  and  T  never 
saw  him  cross  with  a  patient/  He  was  very  attentive  to  his 
wards  and  to  his  hospital  duties,  and  of  course  his  work  was 
done  as  few  but  he  could  do  it.  He  was  kind  and  considerate 
to  his  residents,  and  took  pains  to  teach  them  and  give  them 
a  chance.  He  has  more  than  once  said  to  me,  when  cases 
involving  considerable  were  in  the  wards,  "  Now,  you  take 
this  case;  you  can  do  it,  and  doing  it  will  help  you  at  some 
later  day  in  your  work." 

I  went  through  the  obstetrical  wards  with  Dr.  R.  A.  F. 
Penrose  as  chief.  Penrose  was  thoroughly  up  in  his  spe- 
cialty, and  this  was  before  the  days  of  his  professorship  at 
the  University.  He  was  most  considerate  and  kind  to  his 
residents,  and  took  great  pains  to  teach  them.  I  know  I  was 
under  great  personal  obligations  to  him,  and  when  I  left  his 
wards  I  had  done  over  and  over  again  many  of  the  important 
operations,  such  as  application  of  the  forceps,  etc.,  which 
served  me  well  when  thrown  on  my  own  resources  in  after 
life.  Edward  L.  Duer,  the  accomplished  accoucheur  and 
gynzecologist  of  Philadelphia,  was  one  of  the  visiting  obstetri- 
cians, and  so  was  Frank  F.  Maury,  but  he  resigned  and  took 
the  first  vacancy  in  the  surgical  wards.  Maury  was  a  bright 
man  of  delicate  physique,  was  assistant  to  Professor  Gross 
for  a  long  time,  and  could  do  anything  in  operative  surgery 
he  had  ever  seen  Gross  do.  He  obtained  a  good  practice  in 
general  surgery,  but  was  particularly  well  known  as  a  special- 
ist in  venereal  diseases.  His  health  failed,  and  he  died  a  com- 
paratively young  man. 

Richard  J.  Levis  had  the  surgical  wards  during  the  sum- 
mer term,  and  therefore  had  no  class  for  clinics.  He  was  a 
mastery  in  surgery,  and  was  a  master  mechanic,  and  his  lec- 
ture on  Surgical  Emergencies  should  be  read  by  every  one. 
If  Levis  was  caught  in  an  emergency  without  an  instrument 
he  could  do  more  than  any  man  I  ever  knew  to  supply  the 
defect  then  and  there.  As  an  operator  he  covered  all  the 
domain  of  surgery,  from  a  hip- joint  case  to  the  most  delicate 
operation  on  the  eye.     He  did  little  literary  work,  and  the 

63 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

result  of  his  labors  was  mostly  buried  with  him  when  he 
died. 

Da  Costa  had  charge  of  the  medical  wards,  and  gave  his 
clinics  twice  a  week.  He  brought  to  bear  in  his  work  at 
Blockley  the  same  great  ability  he  has  always  exercised,  and 
did  great  work  for  both  students  and  patients.  Dr.  Alfred 
Stille  was  also  a  visiting  physician,  and  was  scrupulously 
careful  and  exact  in  his  work.  Dr.  Ziegler  had  the  medical 
wards  in  summer,  and  of  course  held  no  clinic.  Dr.  Charles 
Pendleton  Tutt,  a  most  industrious  and  painstaking  physician, 
was  another  of  the  visiting  physicians.  He  had  ward  classes 
of  students  in  the  spring,  and  whilst  devoting  himself  assidu- 
ously to  this  work  took  typhus  fever,  from  the  contagion  in 
his  own  wards.  I  remember  sadly  his  terrible  illness.  Dr. 
Francis  Gurney  Smith  was  his  physician,  and  the  present 
Professor  Tyson,  of  the  University,  Dr.  D.  F.  Woods,  and 
myself  took  care  of  him.  He  died  at  his  home  in  Philadelphia, 
opposite  the  United  States  Mint,  near  Broad  and  Chestnut 
Streets.  I  mention  this  case  here  to  show  the  changes  that 
have  taken  place  since  that  time,  1865,  I  think  it  was.  Here 
was  a  case  of  that  most  loathsome  and  contagious  disease, 
typhus  fever,  in  the  very  midst  of  the  best  part  of  the  city. 
There  was  no  restriction  as  to  those  coming  and  going  from 
the  house.  We  who  were  in  attendance  even  did  not  take 
any,  or,  if  any,  very  few  of  the  precautions  we  would  take 
to-day.  The  funeral  was  not  private,  any  one  going  who  was 
inclined.  I  do  not  remember  that  any  one  took  the  fever  from 
this  case.  This  exemption  was  surely  due  to  the  kindness  of 
an  overruling  Providence  rather  than  to  any  human  agency. 

Now,  as  to  typhus  fever,  this  plague  of  Athens.  In  the 
winter  of  1864-65  we  had  a  serious  epidemic  of  it  inside  the 
walls  of  Blockley.  In  those  days,  in  those  old  out-wards,  the 
homes  of  the  indigent,  it  was  like  poverty,  "  always  with  us," 
and  likely  to  break  out  whenever  the  host  was  available. 
When  I  think  of  how  we  treated  such  cases,  as  to  environ- 
ment, etc.,  I  wonder  we  did  not  all  die.  Indeed,  I  wonder  we 
were  not  all  executed  by  judicial  hanging,  for  I  reckon  we 

'    ■     64 


FORTY    YEAKS    IN    THE    MI-.DICAL    PROFESSION 

should  have  been  hanged  anyh^nv,  hut  the  g(jod  old  hymn  very 
truly  says, — 

"  God  works  in  a  mysterious  way, 
His  wonders  to  perform." 

In  those  days  we  thouglit  a  sick  man  sliould  l)e  kept  well 
housed  and  warm,  no  difference  what  the  trouble.  Many  and 
many  a  time  1,  have  gone  personally  into  the  alcoves  (jr  dens 
in  the  out-wards,  which  the  old  paupers  loved  to  think  of  as 
their  own  home,  and  dragged  (jut  the  inmates,  covered  with 
the  typhus  rash,  with  a  temperature  high  enough  to  almost 
burn  one ;  and  then  the  sickening,  mousy  odor !  They  were 
sent  at  once  to  the  general  medical  wards  and  treated  there ; 
think  of  it !  Dr.  William  H.  Ford,  my  dear  friend,  who  since 
that  time  has  done  sd  much  noble,  able,  and  disinterested 
work,  which  work  only  stopped  the  day  death  overtook  him, 
was  one  of  the  resident  physicians.  As  President  of  the 
Board  of  Health  of  Philadelphia  for  many  years,  by  his  un- 
ceasing care  and  vigilance  he  has  made  all  such  diseases  as 
typhus  fever  impossible  of  spreading  in  epidemic  form  in  the 
great  city,  and  this  work  has  all  been  done  within  a  few  years. 
During  this  epidemic  in  Blockley  I  remember  one  of  the  great 
surgeons  amputating  a  colored  woman's  arm  above  the  elbow. 
I  had  care  of  the  after-treatment.  On  the  third  day  she  de- 
veloped typhus  fever;  she  was  kept  in  her  bed  in  the  ward, 
treated  there,  and  died  there.  She  was  taken  to  the  dead- 
room  after  death.  I  posted  her,  using  only  ordinary  precau- 
tions. The  only  extraordinary  precaution  we  used  was  that 
no  subject  dead  of  a  contagious  disease  went  to  the  anatomi- 
cal rooms  of  the  medical  schools.  The  fever  went  on  through 
the  winter;  none  of  the  physicians  took  it  until  Dr.  Tutt  in 
the  spring,  but  many  patients  and  a  number  of  nurses  suc- 
cumbed. After  the  warm  weather  came  and  the  buildings 
.  were  opened  up,  and  the  gentle  breezes  and  heavy  gales  of 
spring  went  through  the  wards,  the  typhus  contagion  (we 
are  not  sure  to-day  of  its  exact  nature,  although  it  is  probably 
zymotic)  went  out  at  the  windows,  and  this  is  how  the  great 
epidemic  of  1864-65  left  Blocklev.  Let  it  return  now,  we 
5  ^  65     " 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

have  all  grown  in  knowledge  and  prudence,  and  we  Avould 
welcome  it  as  the  unpatriotic  old  Whig,  Tom  Corwin,  wished 
the  Mexicans  to  welcome  our  troops  going  to  Mexico  in  the 
war  of  1847, — "  We  would  welcome  it  with  bloody  hands  to 
hospitable  graves." 

Among  the  resident  physicians  was  John  S.  Parry,  an 
original  thinker  and  one  of  the  brightest  of  men.  He  has 
left  the  profession  a  classic  in  his  work  on  "  Extra-Uterine 
Pregnancy,"  good  authority  to-day,  twenty-two  years  after 
his  early  death,  which  took  place  in  Florida  in  1876,  of  con- 
sumption. Among  the  other  residents  were  Dr.  William  H. 
Wallace,  now  a  prominent  practitioner  in  Philadelphia ;  Wil- 
liam H.  Helm,  now  of  Sing  Sing,  New  York;  William 
McClure,  the  well-known  oculist;  C.  E.  Smith,  of  St.  Paul; 
R.  Stansbury  Sutton,  the  well-known  gynaecologist  of  Alle- 
gheny City;  Dr.  H.  W.  McCoy,  of  Indiana;  Dr.  Robert 
Miller,  of  Kentucky;  and  Dr.  Sparks,  of  Philadelphia.  At 
that  day  the  organization  of  the  hospital,  as  far  as  using  the 
vast  amount  of  clinical  material  at  hand  was  concerned,  was 
very  incomplete ;  the  residents  were  kept  busy,  but  the  pathol- 
ogy was  not  worked  up  in  any  way  approaching  completeness, 
and  it  was  sad  to  see  the  waste  of  so  much  grand  material 
which  could  have  been  made  so  useful.  Even  in  those  days, 
in  advancing  the  science  of  medicine  and  in  educating  those 
in  the  profession,  both  old  and  young,  this  lack  of  organiza- 
tion for  work  was  apparent  in  the  profession  in  general  in 
Philadelphia.  It  was  rare  that  a  proper  interest  could  be 
gotten  up  in  the  general  meetings  of  the  College  of  Physi- 
cians or  of  the  Pathological  Society;  even  if  a  lecture  by 
some  bright  man  should  be  announced  on  some  interesting 
subject,  those  interested  quaked  with  fear  lest  no  appreciative 
audience  might  be  present  to  encourage  the  lecturer.  Pro- 
fessor Gross  was  one  of  the  most  regular  attendants  and 
workers  at  these  meetings,  especially  at  the  Pathological  So- 
ciety. He  was  greatly  interested  in  pathology,  had  written 
on  it,  and  more  than  any  teacher  of  his  day  impressed  its  im- 
portance upon  his  hearers. 

66 


CHAPTER    IV. 

Started  for  Liverpool  in  a  Sail-Ship — Tornado — Narrow  Escape  and 
Return  to  New  York — Better  Success  by  Steamer — Paris  in  1866 — 
The  Hospitals — The  Doctors — Velpeau,  Jobert  de  Lamballc,  Nelaton, 
Ricord,  Sichcl,  Charcot,  Trousseau,  Liebreich,  Pasteur,  J.  Marion 
Sims — Napoleon  III.  and  why  he  failed — Tone  of  the  Profession  in 
Paris — London — Sir  William  Ferguson,  Sir  Thomas  Watson,  Sir 
James  Paget,  and  Others — Edinburgh — Simpson  and  Syme — Ether 
and  Chloroform  —  Berlin  —  Von  Langenbeck  —  Frerichs  —  Vienna  — 
Clinical  Schools  and  Lectures — Billroth,  Skoda,  Oppolzer,  Tiirk,  and 
Others. 

In  1866,  not  being  in  robust  health,  having  been  engaged 
in  private  practice  in  Philadelphia,  I  went  to  Europe  for  the 
dual  purpose  of  recuperating  and  studying  some  of  the  for- 
eign methods  then  in  vogue  in  medicine. 

I  determined  to  try  a  voyage  longer  than  the  usual  steamer 
run  of  a  few  days,  so  took  the  American  clipper  ship  Emerald 
Isle,  Captain  Eves.  I  remember  embarking  at  the  Battery 
and  being  rowed  by  one  of  the  harbor  boatmen  in  a  small  boat 
to  the  ship,  anchored  away  down  towards  the  Narrows,  in  the 
upper  bay.  There  was  an  easterly  storm  blowing  then,  which 
increased  hourly,  and  held  us  at  our  anchor  unable  to  proceed 
for  a  week.  We  had  all  sorts  of  adventures,  being  fouled  by 
other  vessels  carried  from  their  moorings.  At  last  the  wind 
backed  around  to  the  west,  and  on  a  Sunday  morning  the 
captain  came  down  in  a  tug,  and  we  were  soon  under  way.  I 
remember  the  third  mate,  a  rattling  little  Irishman,  made  the 
remark  that  we  were  going  to  sea  under  a  bad  omen, — the 
wind  had  gone  around  the  wrong  way,  had  backed  around, 
and  would  soon  come  back  to  the  storm  quarter  again  and 
give  us  hell,  as  he  expressed  it,  in  a  way  more  emphatic  than 
elegant.  Mr.  Kelly  was  right,  the  storm  did  return,  and  we 
had  a  week  of  terrible  blows  and  hurricanes,  at  the  height  of 
which  our  ship  sprung  a  leak,  was  thrown  on  her  beam  ends, 
leaked  badly,  with  four  and  a  half  feet  of  water  in  her  hold, 

(>7 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

all  her  pumps  choked  with  grain  from  the  cargo,  and  nearly 
every  sail  blown  from  the  bolt-ropes.  A  sad  plight  to  be  in, 
surely.  It  was  not  my  first  experience  at  sea,  but  it  was  my 
worst  experience. 

Nowhere  can  a  man  feel  more  utterly  hopeless  and  dejected 
than  under  such  conditions,  waiting  every  moment  for  his 
ship  to  sink  under  him.  Even  here  the  doctor  comes  in,  as  he 
so  often  does  in  forlorn  hopes.  The  steward  was  an  old 
packet  rat,  a  middle-aged  man,  who  had  been  to  sea  all  his 
life.  During  the  height  of  the  gale  he  was  very,  very  sea- 
sick, and,  to  use  a  sailor's  expression,  had  thrown  up  every- 
thing but  his  boots,  cursing  and  swearing  at  a  terrible  rate  all 
the  time.  In  the  midst  of  one  of  his  worst  paroxysms  I  heard 
the  captain  call  out  to  him,  "  Steward,  let  up  there!  we  are 
in  rough  times ;  you  don't  know  where  you  may  be  this  time 
to-morrow.  I  will  send  the  doctor  to  you."  I  heard  him  yell 
back,  "  Captain,  I  don't  care  a  d — n !  D — n  the  storm !  d — n 
the  ship !  d — n  the  doctor !  I  ain't  afeared  to  die.  I  don't 
want  to  live."  This  shows  the  horrors  of  sea-sickness,  and 
that  there  are  times  in  one's  life  when  even  doctors  are 
scorned. 

After  several  days  the  gale  abated,  and  the  pumps  were 
cleared,  enabling  us  to  keep  down  the  water.  I  will  never  for- 
get the  lovely  morning  when  the  sun  came  out,  giving  us 
summer  temperature,  with  only  a  gentle  tropical  breeze.  The 
ship  lay  there  with  scarcely  a  sail  intact,  listed  very  far  to 
starboard,  and  every  one  utterly  exhausted.  The  captain 
talked  the  matter  over  with  me  and  the  first  officer,  and  we 
agreed  that  every  man  possible  should  have  six  hours  sleep. 
The  first  officer  remarked,  rather  cheerfully,  that  if  the  wind 
came  out  "  norwest"  we  would  never  get  back  to  New  York, 
and  the  ship  could  never  go  to  the  other  side  in  her  present 
condition.  The  captain  said  we  were  two  hundred  and  forty 
miles  from  Sandy  Hook,  and  he  would  endeavor  to  get  her 
back  there  as  soon  as  possible.  After  a  rest  to  the  crew,  every 
one  was  put  to  shifting  the  bags  of  corn  between  decks  to  the 
port  side,  which  had  the  effect  of  easing  the  ship  up  a  little 

68 


FORTY    YEARS    IN    THK    MEDICAL    PROFESSION 

towards  an  even  keel.  yVfter  some  new  sails  had  l^een  bent, 
we  started  back,  took  a  pilot  next  day,  and  soon  a  tug  appeared 
and  took  ns  to  about  the  same  anchorage  in  New  York  liay 
we  had  left  a  week  before.  I  returned  the  life-preserver  Cap- 
tain Eves  had  kindly  strapped  on  me,  and  with  a  light  heart 
said  good-by  to  him  and  his  crew. 

As  his  ship  would  pro1)al)ly  be  delayed  a  month  before 
sailing,  I  secured  passage  in  the  Arago,  Captain  fiadsden,  a 
first-class  wooden  side-wheel  steamship.  I  had  a  lovely  voy- 
age, meeting  several  old  friends,  there  being  only  eighty  first- 
class  passengers  and  none  others.  The  ocean  during  the 
whole  trip  of  fourteen  days  to  Havre  (you  modern  traveller, 
think  of  fourteen  days  to  Europe!)  was  as  calm  as  a  river, 
and  at  no  time  on  the  voyage  was  there  an  hour  we  would  not 
have  been  safe  in  a  batteau  alongside  the  ship.  This  proved 
the  old  sailor's  advice  correct, — wdien  you  are  ready  to  go  to 
sea,  go;  don't  wait  for  weather;  you  can  never  tell  what  is 
coming. 

We  got  our  first  glimpse  of  England  in  Falmouth  harbor, 
where  we  arrived  early  in  the  morning,  and  crossing  the 
channel,  passing  close  by  the  celebrated  Eddystone  Light- 
House,  we  arrived  at  Havre  in  due  time,  and  entering  the 
locks  were  hoisted  up  into  that  wonderful  artificial  basin,  the 
harbor  of  Havre,  large  enough  to  hold  five  hundred  ships  the 
size  of  the  Arago.  Through  Normandy,  with  a  short  visit  to 
Rouen,  inspecting  the  great  Cathedral  and  the  scene  of  the 
burning  of  Joan  d'Arc,  we  Avere  soon  in  gay  and  lovely  Paris. 
After  looking  around  for  a  few  days,  paying  visits  to  friends 
and  delivering  letters,  I  soon  took  up  the  object  of  my  visit 
and  began  to  look  up  matters  pertaining  to  medicine. 

These  were  the  days  of  the  second  empire,  and  Louis  Na- 
poleon was  at  the  very  acme  of  his  power.  All  this  had  its 
effect  upon  medicine,  and  only  those  in  favor  of  the  ruling 
power  could  expect  positions  of  emolument  and  distinction. 

The  most  striking  character  I  met  in  Paris,  and  the  one 
who  impressed  me  most  among  medical  men  was  Velpeau. — 
Alfred  Armand  Louis  JMarie  \^elpeau.     I  suppose  one  reason 

69 


FORTY    YEARS    IN    THE    MEDICAL'  PROFESSION 

of  this  was  that  in  my  day  students  probably  heard  most  fre- 
quently the  name  of  Velpeau,  of  all  foreign  doctors,  for  he 
was  great  and  eminent  in  two  great  specialties,  surgery  and 
obstetrics;  in  fact,  he  was  a  great  all-round  man  in  the  pro- 
fession. He  was  of  obscure  origin ;  in  other  words,  entirely  a 
self-made  man.  I  first  saw  him  in  the  wards  of  La  Charite, 
busy,  going  around  among  the  beds  early  in  the  morning, 
with  a  number  of  students  with  him.  He  was  rather  a  tall, 
spare  man  as  I  remember  him,  in  ordinary  dress,  the  top  of 
his  head  adorned  with  a  green  velvet  skull-cap,  which  he 
always  wore  during  his  hospital  work.  He  had  a  note-book 
and  pencil  in  his  hand,  in  which  he  took  copious  notes  as  he 
proceeded  on  his  rounds.  The  old  gentleman  was  generally 
good-natured,  often  joking,  yet  a  strict  disciplinarian.  He 
was  at  this  time  seventy-one  years  of  age.  When  he  was 
thirty-five  he  was  surgeon  at  Pitie,  and  worked  until  he  died, 
August  4,  1867. 

Jobert  de  Lamballe  was  another  interesting  character  and 
great  surgeon,  with  an  especial  reputation  in  plastic  opera- 
tions. He  was  a  very  rapid  operator.  It  is  said  of  him  that 
when  everything  was  ready  for  a  shoulder- joint  operation  in 
his  clinic,  he  would  pick  up  a  knife,  count,  with  deliberation, 
un,  deux,  trois,  and  the  disarticulation  was  accomplished  in 
three  movements  of  the  knife.  He  was  an  irritable  old  fellow, 
always  ready  for  a  fight,  as  were  most  of  the  Paris  doctors, 
and  it  was  not  uncommon  for  one  great  surgeon,  when  lec- 
turing before  a  class,  to  speak  of  some  other  great  surgeon  as 
"  the  Httle  butcher  around  the  corner."  I  saw  little  of  Jobert 
de  Lamballe,  as  he  had  about  given  up  work,  and  died  in  a 
year  or  two  after  this  time. 

Auguste  Nelaton  was  probably  the  most  popular  surgeon 
as  a  practitioner  at  this  period  in  Paris.  He  was  an  elegant- 
looking  man  and  a  most  accomplished  gentleman.  A  Pari- 
sian by  birth,  he  was  a  pupil  of  the  great  Dupuytren.  He 
wrote  little,  but  was  for  a  long  time  Professor  of  Clinical 
Surgery.  Later  he  was  made  a  senator  of  France,  and  was  a 
member  of  the  Academy.    All  of  these  honors  were  showered 

70 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

upon  him  out  of  the  gratitude  of  Napoleon  III.,  whose  friend 
and  surgeon  he  was.  Nelaton  was  a  very  a1)le  and  cajjable 
genito-urinary  surgeon,  and  a  man  oi  great  mechanical  inge- 
nuity and  resources,  as  his  celebrated  Garibaldi  porcelain- 
pointed  probe  attests.  Speaking  of  the  friendship  of  Napo- 
leon III.  for  Nelaton  brings  up  a  matter  in  which  these  great 
men  were  actors,  and  which  I  have  always  believed  was  a 
great  factor  in  the  downfall  of  the  unhappy  emperor,  and  had 
very  great  possible  effect  on  the  modern  history  of  Europe. 
The  matter  I  speak  of  came  to  me  very  directly  from  profes- 
sional sources.  Napoleon  III.  had  suffered  for  a  long  time 
from  organic  stricture  of  the  urethra  and  its  attendant  trou- 
bles. Nelaton  was  his  surgeon,  and  when  he  was  about  fifty- 
five  years  of  age  Nelaton  was  compelled,  after  having  done 
many  minor  operations,  to  make  a  very  complete  and  radical 
operation  and  form  practically  a  new  urethra.  Any  one 
familiar  with  such  operations,  and  with  the  conditions  before 
and  after  such  operations,  knows  too  well  the  sufferings  at- 
tendant upon  such  an  existence.  Probably  for  ten  years  pre- 
vious to  his  downfall  Napoleon  III.  was  a  terrible  sufferer, 
and  doubtless  could  give  little  thought  to  the  details  of  states- 
manship or  government.  Those  around  him  became  corrupt, 
the  whole  administration  of  the  government  became  cor- 
rupted, and  when  he,  with  the  puny  will  and  sickly  judgment 
of  one  w^eighed  down  with  all  the  cruel  sufferings  such  as  he 
sustained,  led  poor  France  into  the  Franco-Prussian  War, 
then,  and  not  until  then,  did  the  truth  dawn  upon  him  of  the 
absolute  hollow  rottenness  of  his  government  and,  as  a  natu- 
ral result  to  all  this,  the  thorough  inefificiency  of  his  army. 
The  sorrowful  surrender  at  Sedan  marked  the  downfall  of 
this  unfortunate  man,  and  his  death  at  Chiselhurst,  England, 
in  January,  1873,  whilst  undergoing  the  operation  of  crush- 
ing for  stone  in  the  bladder,  under  the  direction  of,  and  by  the 
skilful  hands  of,  Sir  Henry  Thompson,  only  confirms  the 
view  I  have  here  given  of  his  case,  and  shows  that  his  horri- 
ble vesical  suft'erings  pursued  him,  beaten,  humiliated,  and 
exhausted,  to  the  very  brink  of  his  grave.     Nelaton  died  in 

71 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Paris,  in  September,  1873,  only  a  few  months  after  his  great 
benefactor. 

Malgaigne,  one  of  the  greatest  of  French  surgeons,  died 
about  this  time.  He  is  best  remembered  to-day  as  the  intro- 
ducer of  Malgaigne's  hooks  for  holding  together  the  divided 
fragments  in  fracture  of  the  patella,  an  instrument  which  has 
not  met  with  great  favor  by  the  profession,  but  in  the  present 
days  of  antisepsis  is  less  dangerous  than  formerly. 

Civiale  was  a  great  authority  also  in  Paris  at  this  date, 
1866.  He  worked  persistently  and  intelligently,  opposed  by 
Velpeau,  Nelaton,  and  other  great  surgeons,  on  his  hobby 
of  crushing  stone  in  the  bladder,  instead  of  cutting  for  it. 
He  perfected  his  lithotrites  and  other  instruments,  and  has  his 
justification  to-day;  and  were  he  alive  he  would  see  his  oper- 
ation an  unqualified  success,  without  limitation  as  to  years  or 
sex,  and,  with  the  improvements  of  Bigelow,  the  American 
surgeon,  and  others,  see  still  greater  triumphs  in  the  imme- 
diate evacuation  of  the  debris. 

Cloquet  was  a  well-known  surgeon,  and  perhaps  the  best 
anatomist  of  his  day  in  Paris. 

Philippe  Ricord  was  the  great  authority  on  venereal  dis- 
eases, and  although  born  in  Baltimore,  Maryland,  was  a  true 
Parisian.  He  served  at  the  Hopital  du  Midi  and  was  won- 
derfully active,  a  great  experimenter,  not  sparing  even  him- 
self. He  was  now  well  on  to  seventy  years  of  age,  still  active, 
with  an  enormous  clientele,  as  the  great  authority  of  his  day 
on  his  specialty. 

On  the  eye,  Liebreich  was  the  man  I  saw  most  of,  and 
probably  had  the  greatest  reputation  at  the  time,  although  I 
think  Sichel,  whom  I  never  saw  to  know,  had  been  for  years 
the  great  oculist  of  the  city.  I  saw  Liebreich  operate  a  good 
deal,  and  he  was  very  expert.  He  appeared  to  seek  and  do  a 
great  number  of  operations  for  strabismus,  and  always  su- 
tured the  conjunctiva  with  very  fine  silk.  I  thought  the 
after-effects  were  bad,  and  I  imagine  he  did  not  keep  it  up. 
With  aseptic  precautions  sutures  might  do  better.  Liebreich 
was  a  tall,  spare  man.  of  very  dark  complexion  and  very  black 

72 


FORTY    YRARS    IN    TUK    MKDfCAL    PROFESSION 

hair;  he  lor)l<e(l  Hke  a  Spaniard.  He  probably  came  from 
over  the  Rhine,  or  very  near  it.  He  was  not  a  Frenchman, 
and  I  think  was  compelled  to  leave  Paris  in  a  hurry  when  the 
Franco-German  War  came  on.  1  think-  he  went  to  London, 
but  I  am  not  sure. 

As  every  one  knows,  Paris  is  full  of  lio.spitals,  and  presents 
the  greatest  advantages  for  clinical  study.  As  I  remember 
them,  La  Charite  and  the  Llotel  Dieu  were  the  great  and  in- 
teresting ones.  They  were  internally  very  old  and  ram- 
shackle in  their  appearance.  They  were  kept  scrupulously 
clean,  but  there  appeared  to  be  plenty  of  harbor  for  rats,  mice, 
roaches,  and  other  vermin.  Their  organization  was  superb 
for  that  day,  and  their  great  advantages  were  not  allowed  to 
go  to  waste,  whether  clinical,  pathological,  or  histological.  I 
remember  Fournier  and  Logier  as  great  hospital  workers,  and 
they  rarely  visited  the  institutions  without  spending  some 
time  in  the  dead-house. 

Trousseau  died  in  1867,  and  to  the  day  of  his  death  was  the 
great  physician  of  Paris  of  his  time.  He  made  a  great  spe- 
cialty of  diphtheria,  and  worked  up  tracheotomy  as  no  other 
man  had  done  before  him.  He  was  a  tremendous  worker, 
was  Professor  of  Therapeutics,  and  worked  up  paracentesis 
thoracis  in  chronic  pleuritic  efifusion,  besides  all  troubles  con- 
nected with  the  windpipe.  Claude  Bernard  was  the  great 
physiologist  of  this  time,  and  was  an  indefatigable  and  origi- 
nal worker  and  experimenter;  indeed,  no  man  approached 
him  in  his  special  lines.  He  died  in  1878,  when  experimental 
physiology  lost  her  great  and  shining  light.  Dr.  Campbell 
was  the  great  obstetrician  of  Paris,  and  Dr.  Beylard.  who 
came  from  Philadelphia,  was  the  favorite  physician  of  the 
American  colony,  and  was  a  great  and  good  friend  to  me 
during  my  residence  in  the  city. 

One  of  the  most  interesting  times  Paris  has  ever  seen  in 
her  medical  history  was  upon  the  advent  of  the  great  sur- 
geon, J.  Marion  Sims,  within  her  borders  in  1861.  No  man 
doubts  to-day  that  Sims  was  a  great  man:  no  man  doubts 
that  he  was  one  of  the  great  men  of  the  world :   and  no  man, 

73 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

if  he  be  true  to  himself,  doubts  that  Sims  was  one  of  the  chief 
founders  of  the  art  of  gynaecology,  and  almost  personally  and 
absolutely  the  founder  of  plastic  gynaecological  operations.  I 
doubt  if  the  tone  of  the  profession  in  Paris  was  ever  good. 
The  whole  business  always  has  been  constantly  riddled  with 
professional  jealousies  and  hopelessly  divided  into  cliques  of 
the  most  ultra  and  inharmonious  natures. 

The  causes  of  this  state  of  affairs  are  easily  to  be  seen  when 
one  makes  a  study  of  the  conditions.  The  divisions  into 
cliques  is  the  first  cause,  and  these  cliques  are  intensely 
jealous  of  each  other,  and  let  pass  no  occasion  to  abuse  each 
other,  even  in  the  public  lecture-halls.  Next,  the  individuals 
abuse  each  other,  and  they  carry  these  personal  quarrels  with 
them  in  their  daily  rounds,  and  retail  them  to  their  patients, 
and  thus  the  patients,  becoming  imbued  with  the  scandals, 
retail  them  to  their  friends;  hence  society  in  Paris  is  full  of 
the  medical  scandals  of  the  day.  They  gloat  over  them,  and 
of  course  the  scandals  gather  as  they  go,  and  it  is  a  common 
thing  to  hear  details  of  Dr.  So-and-so's  great  and  successful 
operation,  and  of  Dr.  Somebody-else's  lamentable  failure 
under  like  conditions.  When  Sims  entered  Paris  the  tongues 
began  to  wag.  His  fame  had  preceded  him,  especially  as  to 
his  success  in  vesico-vaginal  fistula.  There  were  cases  in 
Paris,  in  fact,  all  over  France,  where  Nelaton  had  pronounced 
cure  impossible,  where  Velpeau  had  seconded  Nelaton  in  a 
like  opinion,  and,  more  than  that,  where  Jobert  de  Lamballe, 
the  great  plastic  surgeon  of  the  French,  had  failed  inglo- 
riously.  Sims  took  up  these  cases,  and  in  the  presence  of  the 
great  lights,  Velpeau,  Nelaton,  and  others,  operated  on  them 
and  cured  them.  It  was  a  great  triumph  for  Sims,  a  great 
set-back  for  the  boasted  priority  of  French  surgery.  Although 
they  had  to  recognize  Sims  and  his  great  successes,  they  con- 
tinued to  belittle  him  and  abuse  him. 

I  remember  one  night  attending  a  large  private  dinner  of 
gentlemen,  composed  chiefly  of  those  who  were  permanent 
residents  of  Paris,  belonging  to  the  so-called  American  col- 
ony.    As  is  usual  on  such  occasions,  the  rows  among  the 

74 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

French  doctors  came  in  as  part  of  tlie  conversation.  Sims 
came  up  among  others.  Tlie  guests  appeared  to  be  mostly  in 
favor  of  the  Parisians;  few  said  anything  in  favor  of  Sims, 
but  now  and  again  one  would  quote  something  Velpeau  had 
said  slighting  him,  or  something  Nelaton  had  said.  I  remem- 
ber one  man  particularly,  who  said  that  a  few  days  before  he 
had  casually  met  Ricord  coming  out  of  a  hotel,  that  Ricord 
had  stopped  him,  asking,  "  And  do  you  know  our  friend  the 
new  American  Dr.  Seems?  Who  is  this  Dr.  Seems,  any- 
how?" The  only  real  friend  and  defender  Sims  appeared  to 
have  among  the  local  guests  was  one  gentleman  who  defended 
him  lustily,  and  Mr.  Pepper,  who  sat  next  to  me,  told  me  that 
some  time  before  Dr.  Sims  had  performed  an  ovariotomy  on 
his  wife,  to  which  operation  she  had  succumbed,  and,  he 
added,  he  loved  her  dearly,  too. 

In  those  days  Paris  was  a  superb  place  of  residence  for  a 
foreigner,  so  clean,  so  thoroughly  policed,  and  very  inexpen- 
sive. You  could  live  as  a  prince  and  be  thoroughly  comforta- 
ble, and  be  equally  as  comfortable,  only  less  luxurious,  on  a 
few  francs  a  day.  So  long  as  I  remained  there  I  never  saw 
any  trouble,  such  as  brawls  or  street  rows,  and  the  only  really 
drunken  man  I  ever  met  was  the  man  who  undertook  to  drive 
me  to  the  station  on  my  final  leave-taking  for  London.  I  sent 
for  a  cab,  and  when  it  came  I  got  in  with  my  luggage,  not 
noticing  the  driver  more  than  to  tell  him  where  to  go.  Soon 
I  found  myself  in  a  trench  on  the  Boulevard.  Fortunately,  I 
was  on  top,  the  driver  and  horse  under  me.  In  a  few  mo- 
ments I  was  quietly  lifted  out,  and  soon  after  me  the  driver, 
helplessly  drunk,  as  I  saw,  the  cab  and  horse  being  reserved 
for  a  proper  lifting  apparatus,  which  soon  arrived.  No  crowd 
was  permitted  to  gather;  there  was  no  noise,  no  confusion. 
In  a  few  moments  an  of^cer  gently  tapped  me  on  the  arm, 
pointed  me  to  a  fresh  cab,  where  I  found  my  luggage  all  safe, 
and  was  soon  on  my  way  to  the  station  again.  Thus  I  cele- 
brated my  departure  from  enchanting  Paris,  and  with  fond 
anticipations  of  my  visit  to  merry  England,  I  was  soon  on  my 
way  to  the  channel. 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

At  this  time  in  England,  1866,  London  was  supposed  to 
have  the  best  physicians  in  all  Europe,  and  to  Paris  was  given 
the  pre-eminence  for  surgeons.  When  we  come  to  review  the 
list  of  surgeons  in  England  and  Scotland  and  Ireland,  such  a 
review  does  not  appear  to  strengthen  this  claim :  Sir  William 
Ferguson,  of  London,  was  the  peer  of  any  man  of  his  day, 
and  in  some  of  his  special  plastic  operations  was  probably  un- 
equalled; Sir  James  Paget,  the  great  authority  on  surgical 
pathology;  Bowman,  undoubtedly  the  most  skilful  operator 
on  the  eye  of  his  time ;  Annandale,  Heath,  Hewitt,  all  great 
surgeons;  and  last,  but  not  least,  Mr.  Lister,  then  of  Edin- 
burgh, afterwards  Sir  Joseph  Lister,  and  now  Lord  Lister,  of 
London,  the  great  apostle  of  antisepsis,  whose  wife  did  so 
much  to  help  him  in  his  work,  a  daughter  of  the  great  James 
Syme,  and  who  lately  died,  leaving  her  famous  husband  bereft 
and  inconsolable;  Toynbee  and  Wilde,  the  great  aurists  of 
their  day;  Syme,  the  wizard  of  Edinburgh;  Sir  James  Y. 
Simpson,  his  great  antagonist,  unapproached  in  his  day  as 
an  obstetrician,  gynsecologist,  and  surgical  specialist,  and  in- 
ventor, too ;  Lizars ;  Matthews  Duncan,  student  of  Simpson ; 
Sir  Spencer  Wells,  and  other  noted  names  by  the  dozen,  show 
the  English  people  to  have  been  no  laggards  at  that  day  in 
the  world's  race  for  surgical  honors. 

Sir  Thomas  Watson,  the  nestor  of  the  London  physicians, 
honored  by  royalty  and  plebeian  alike,  lived  almost  a  full  cen- 
tury, and  gave  to  the  profession  a  monumental  work  in  his 
"  Practice  of  Physic,"  which  for  lucidity  of  thought,  beauty 
of  expression,  and  as  a  specimen  of  finished  literary  style  and 
pure  Anglo-Saxon  English,  has  been  rarely  approached  and 
surely  never  excelled  by  any  work  in  medical  literature. 
Coming  after  Watson,  the  names  of  Jenner,  Gull,  Garrod, 
Todd,  Thomas  King  Chambers,  Fothergill,  Clark,  and  scores 
of  others  attest  her  claim  as  a  centre  of  medicine  and  medical 
science.  At  this  date,  the  names  of  Tyndall,  in  England,  and 
Pasteur,  in  France,  were  comparatively  little  known,  and 
Koch  was  probably  a  child  in  kilts.  Since  that  time  these 
men  have  grown  to  be  giants,  and  the  great  Pasteur  has 

76 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

passed  away  to  join  the  silent  majority.  Whilst  Tyndal!  is 
great,  whilst  Koch  is  great,  J.ouis  Pasteur  was  the  greatest, 
to  my  mind,  among  all  scientists  of  his  class  who  has  yet  lived. 
Think  of  what  this  man  has  done  and  what  a  pioneer  he  was ! 
No  one  had  blazed  the  way  for  Pasteur  in  his  great  experi- 
ments, and  no  one  has  approached  him  in  the  good  done  to 
mankind,  for,  even  without  Pasteur's  work,  I  doubt  if  to-day 
we  would  have  been  advanced  to  the  point  we  are  in  anti- 
sepsis and  asepsis.  No  wonder  France  is  proud  of  Pasteur, 
and  has  done  great  honor  to  his  memory.  He  saved  her  in- 
dustries and  almost  her  very  existence  in  his  combat  with  and 
investigations  into  the  silkworm  disease.  He  found  the  moth 
with  the  concentric  rings  to  be  the  cause  of  the  trouble ;  de- 
stroy these  moths,  destroy  their  eggs,  said  Pasteur,  and  the 
silk  industry  was  saved  to  France.  He  did  equal  service  in 
his  investigations  into  the  fermentation  of  wines,  destroying 
the  germs  by  high  temperature.  So  with  the  anthrax  pest, 
so  with  the  diseases  of  the  vines,  did  he  wrestle  and  conquer. 
But  above  all  these,  oh,  that  great  boon  to  those  unfortunates 
who  have  suffered  from  the  bite  of  the  rabid  animal !  Oh, 
the  pangs,  the  horrors,  the  terrible  forebodings  these  poor 
unfortunate  people  suffered  before  this  work  of  Pasteur  with 
the  virus  of  rabies!  His  methods,  his  careful  \vorkings,  his 
results,  almost  approach  inspiration.  At  this  work,  after 
these  results,  even  there  are  scoffers,  those  who  say  there  is 
no  such  disease  as  hydrophobia  in  a  human  being.  Away 
with  such !  I  have  seen  it ;  I  have  seen  it  in  man  approach- 
ing old  age;  in  man  in  the  vigor  and  strength  of  youth; 
yes,  I  have  seen  it  in  a  little  child,  who  never  gave  a  thought 
to  his  condition  after  the  first  pain  of  the  bite  subsided,  and 
who  never  even  knew  he  had  a  nerve  or  felt  a  nervous  twang 
in  his  short  life.  Yes,  there  is  such  a  disease  as  hydrophobia; 
it  has  been  proved  bacteriologically  from  the  human  being  to 
the  lower  animal,  and  that  ends  the  discussion. 

The  utility  of  Pasteur's  treatment  is  now  generally  ac- 
knowledged ;  even  the  Germans  acknowledge  it,  and  have 
established  centres  for  carrying  it  out.     Hydrophobia  is  the 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

disease  in  man  communicated  to  him  by  a  rabid  animal. 
Rabies  is  the  same  disease  in  the  lower  animal,  or  supposed  to 
be.  Both  are  infectious,  although  the  micro-organisms  of 
neither  have  as  yet  been  isolated.  In  the  treatment  of  hydro- 
phobia Pasteur  has  stepped  in  advance  of  the  bacteriologist, 
for  in  the  other  diseases  treated  with  the  products  of  the 
biologic  activity  of  their  germ  causation,  the  micro-organism 
has  been  separated  and  identified  before  the  therapeutic  agent 
has  been  separated  and  used.  Pasteur's  treatment  of  hydro- 
phobia is  just  the  opposite.  I  have  little  doubt  but  that  the 
micro-organism  of  rabies  will  soon  be  found,  and  establish 
the  Pasteur  treatment  of  hydrophobia  rationally  and  accepta- 
bly to  the  most  exacting  of  scientists. 

A  most  interesting  matter  in  connection  with  hydrophobia 
is  the  so-called  rabies  mephitica,  hydrophobia  from  the  bite 
of  the  common  skunk,  the  mephitis  mephitica,  a  very  com- 
mon little  animal  which  generally  makes  its  presence  known. 
Its  habitat  is  from  Hudson's  Bay  to  Mexico.  The  more 
southern  ones  have  more  white  coloring  and  are  smaller  than 
the  northern  ones.  I  suppose  it  is  also  known  in  Europe,  as 
the  French  call  it  I'enfant  du  diable,  or  the  devil's  own.  The 
fluid  having  the  skunk  odor  is  in  no  way  connected  with  the 
urine,  as  is  generally  supposed,  but  is  secreted  by  two  glands, 
one  each  side  of  the  anus,  called  anal  glands.  Voluntary 
muscles  control  the  fluid  secreted  by  a  number  of  smaller 
glands  around  the  reservoir  for  holding  the  fluid.  The  tail 
has  nothing  to  do  with  the  squirting  or  dashing"  of  the  fluid. 
The  fluid  is  for  defence  and  offence.  This  is  the  so-called 
mephitic  battery,  and  when  it  opens  on  you,  look  out !  Until 
the  fluid  of  this  battery  is  all  discharged  he  rarely,  if  ever, 
bites,  and  this  fact  will  be  found  of  importance  farther  on. 
The  fluid  contained  by  the  gland  is  not  of  large  amount,  and 
the  animal  is  harmless  in  this  respect  until  more  is  secreted, 
which  takes  some  time.  The  animal  can  squirt  the  fluid  from 
six  to  eight  feet  when  he  discharges  his  battery.  The  fluid  is 
phosphorescent  at  night,  and  at  a  distance  when  discharged 
looks  like  a  puff  of  white  smoke  or  a  puff  of  steam  in  daytime. 

78 


FORTY    YICAKS    IN    THE    MEDICAL    J'KOFESSION 

If  too  freely  inhaled  by  man,  it  causes  nausea  and  cramps.  Tn 
minute  doses  it  is  said  to  be  antispasmodic. 

These  matters  are  all  thoroughly  treated  of  by  the  late  Dr. 
Elliott  Crues,  U.  S.  A.,  in  his  work  on  the  "  Fur-Rearing-  Ani- 
mals of  North  America,"  and  1  beg  to  acknowledge  my  in- 
debtedness to  this  work,  and  to  the  articles  by  the  Rev.  Horace 
C.  Hovey  and  Dr.  John  G.  Janeway,  U.  S.  A.,  published  in  Dr. 
Crues's  book.  Mr.  Hovey  claims  that  rabies  from  skunk-bite 
is  a  different  species  of  rabies  from  rabies  canina  and  other 
forms  of  rabies.  He  proposes  the  name  Rabies  Mephitica. 
He  claims  that  rabies  mephitica  is  caused  by  a  special  virus 
generated  by  skunks ;  that  possibly  there  may  be  a  causative 
connection  between  the  inactivity  of  the  anal  glands  and  the 
generation  of  a  malignant  virus  in  the  glands  of  the  mouth. 
As  I  take  it,  he  believes  the  skunk-bite  is  always  followed  by 
rabies  mephitica;  that  the  skunk  only  bites  when  his  me- 
phitic  battery  is  exhausted,  and  his  bite  then  always  produces 
hydrophobia.  Old  hunters  in  the  Rockies,  he  says,  all  believe 
the  bite  of  the  skunk  is  always  fatal,  producing  hydrophobia. 
I  would  suppose  the  mephitic  battery  of  the  skunk  with  hy- 
drophobia would  always  be  empty,  from  the  convulsive  nature 
of  the  disease.  The  muscles  controlling  the  battery  are  vol- 
untary in  health,  but  with  rabies  would  be  affected  by  either 
clonic  or  tonic  spasm. 

Hovey  claims  the  spasms  of  rabies  canina  are  tonic,  and  of 
rabies  mephitica  are  clonic;  that  morphia  acts  in  rabies  me- 
phitica, and  does  not  act  in  very  large  doses  in  rabies  canina. 
Hovey  asks,  "  Do  skunks  take  and  give  rabies,  or  are  they 
among  the  animals  that  spontaneously  generate  a  poison  in 
the  glands  of  the  mouth  and  communicate  it  by  salivarv  inoc- 
ulation?" 

Surgeon  M.  M.  Spearer,  U.  S.  A.,  gives  an  account  of  four 
cases  of  skunk-bite.  He  thinks  there  is  a  marked  difference 
between  the  symptoms  and  those  of  hydrophobia.  The  four 
cases  were  all  fatal.  He  says  the  skunk  virus  is  as  peculiar  to 
it  as  that  of  the  rattlesnake  is  to  it,  and  is  not  an  occasional 
outbreak  of  disease  like  the  sestus  veneris  of  the  wolf,  or  the 

79 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

rabies  canina.  The  instinct  of  the  dog  shows  this.  He  is  as 
cautious  A\hen  attacking  skunks  as  when  he  attacks  venomous 
snakes,  and  is  seldom  bitten.  Hovey  says  the  skunk  is  of  the 
North  American  mustehdcC,  and  if  this  is  true  the  mustehdse, 
as  well  as  the  felidse  and  canidse,  can  communicate  rabies,  or 
a  new  disease  communicated  by  the  mustelidse  has  been  dis- 
covered, which  generically  resembles  rabies  canina,  whilst  dif- 
fering from  it  specifically.  Hovey  thinks  we  might  go  so  far 
as  to  seek  a  solution  of  the  whole  dread  mystery  of  hydropho- 
bia in  the  theory  that  this  awful  malady  originates  with  the 
allied  genera  of  mephitis  (skunks),  putorius  (minks),  and 
mustela  (weasels),  being  from  them  transferred  to  the  cat 
and  the  dog  and  other  families  of  animals.  Harvey  suggests 
that  the  defensive  fluid  of  the  skunk  might  be  found  to  be  the 
natural  antidote  to  the  salivary  virus.  Well,  as  to  this,  na- 
ture, we  know,  generates  her  poisons,  why  not  her  antidotes  ? 
These  suggestions  of  Hovey's  were  made  twenty-five  years 
ago,  and  since  that  time  Pasteur  has  taught  us  enough,  at 
least,  to  make  all  victims  of  the  bites  of  rabid  animals  hope- 
ful, when  before  all  were  given  over  to  despair  and  almost 
hopeless  horror.  Surgeon  John  G.  Janeway  in  his  article 
does  not  agree  with  Hovey  in  the  main,  but  does  agree  in 
part.  He  does  not  believe,  with  Hovey,  that  mephitic  inocu- 
lation is  sure  death.  He  has  known  men  and  dogs  frequently 
bitten,  and  they  did  not  go  mad.  I  may  add  here,  men  and 
dogs  are  frequently  bitten  by  mad  dogs  and  cats,  and  yet  do 
not  go  mad.  The  reason  is,  they,  although  bitten,  were  not 
inoculated,  owing  to  some  circumstance,  as  clothing  or  some- 
thing of  that  kind  absorbing  the  virus  before  the  fang  of  the 
biting  animal  has  entered  the  flesh.  It  is  said  the  skunk  most 
frequently  bites  man  on  the  face,  hand,  ear,  or  other  exposed 
parts,  and  Janeway  admits  that  the  bite  of  the  skunk  oftener 
than  any  other  animal  produces  hydrophobia,  and  gives  this 
as  a  reason.  Janeway  says  the  rabid  skunk  at  once  exhausts 
his  battery,  and  has  little  or  no  odor,  then  they  bite,  as  Hovey 
says. 

In  hydrophobia  the  virus  affects  the  eighth  pair  of  cranial 

80 


FORTY    YEARS   IN   THE   MEDICAL   PROFESSION 

nerves  and  their  l)ranclics,  especially  the  rjcsopbaj^cal  l)ranch, 
the  result  being  the  well-known  difficulty  in  swallowing-. 
The  motor  nerve  of  the  larynx  is  also  affected,  causing  sigh- 
ing, catching  of  the  breath,  and  difficulty  in  expelling  the 
frothy  mucus  accumulated  in  the  throat.  Hovey  and  Jane- 
way  agree  that  these  troubles  are  more  serious  in  rabies 
canina  than  in  rabies  mephitica,  that  the  periods  of  incubation 
of  the  two  are  al)out  the  same,  and  that  man  has  never  been 
known  to  inoculate  man.  All  authorities  and  all  experience, 
I  believe,  agree  on  this  point.  Janeway  concludes  by  de- 
claring that  rabies  or  hydrophobia  produced  by  the  skunk  is 
the  same  rabies  or  hydrophobia  produced  by  the  dog  or  cat 
or  similar  animals.  My  own  experience  agrees  with  that  of 
Janeway,  that  dogs  and  men  bitten  by  skunks  do  not  always 
die  from  the  bite,  either  of  hydrophobia,  rabies,  or  other  trou- 
ble of  the  kind ;  but  I  am  free  to  confess  there  is  something 
peculiar  and  interesting  in  this  study  of  the  bite  of  the  skunk 
and  its  effects.  These  oddities,  or  apparent  oddities,  in  na- 
ture are  interesting  and  most  alluring,  and  all  these  peculiari- 
ties connected  with  the  mustelidae  in  contradistinction  to  the 
same  matters  connected  with  the  felidse  and  canidse  are 
worthy  of  the  closest  study  and  most  watchful  scrutiny.  God 
bless  the  memory  of  Louis  Pasteur ! 

Probably  the  most  unique  character  in  the  profession  in 
the  British  Isles,  if  not  in  all  Europe,  at  this  date  was  Sir 
James  Young  Simpson,  of  Edinburgh,  a  Scotchman  by  birth. 
He  was  a  person  w4th  a  leonine  head,  yet  was  one  of  the 
gentlest  of  men.  He  and  Syme  were  always  squabbling, 
but  Syme  was  the  more  aggressive,  and  was  very  intolerant 
as  to  Simpson,  whom  he  considered  a  mere  obstetrician,  and 
not  entitled  to  any  opinion  of  his  own  on  any  matter  pertain- 
ing to  surgery,  and  more  than  once  made  the  public  state- 
ment that  nothing  of  importance  or  of  good  in  surgery  could 
ever  emanate  from  the  brain  of  an  obstetrician.  Simpson  was 
a  most  wonderful  man,  as  gynaecologist,  obstetrician,  sur- 
geon, and  scientist,  and,  above  all,  as  the  discoverer  of  the 
anaesthetic  properties  of  chloroform  and  the  introducer  of 
6  8i 


■       FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

anaesthesia  into  obstetrical  practice,  and  as  one  of  the  intro- 
ducers and  perfecters  of  acupressure,  at  one  time  much  used 
for  securing  blood-vessels,  but  now  generally  barred  by  the 
introduction  of  aseptic  methods  with  animal  ligatures.  In 
regard  to  the  use  of  anaesthesia  in  labor,  he  had  quite  a  con- 
troversy with  the  late  Professor  Charles  D.  Meigs,  of  Phila- 
delphia, who  opposed  it  bitterly,  claiming  that  labor  was  a 
physiological  process,  and  we  had  no  right  to  dull  its  pangs 
by  artificial  methods.  Simpson  held  to  his  views,  and  to-day 
such  methods  are  in  general  use. 

I  am  fully  persuaded,  so  far  as  my  own  experience  goes, 
that  whilst  the  use  of  anaesthetics  in  labor,  when  properly 
guarded,  is  perfectly  safe  as  to  general  conditions,  and  causes 
woman  to  remember  her  great  trial  only  as  a  pleasant  dream, 
yet  at  the  same  time  it  frequently  interferes  with  prompt  ute- 
rine contractions,  and  renders  the  patient  more  liable  to  post- 
partum hemorrhage. 

When  I  first  entered  the  profession  in  the  United  States 
Marine  Hospital  in  San  Francisco  I  saw  nothing  but  chlo- 
roform used  as  an  anaesthetic.  In  the  clinics  of  the  Uni- 
versity of  Pennsylvania,  during  the  service  of  Professor 
Henry  H.  Smith,  a  mixture  of  chloroform  and  ether  was 
used,  and  sometimes  the  A.  C.  E.  mixture.  Agnew  pre- 
ferred ether,  and  Gross  was  very  partial  to  chloroform,  and 
if  using  ether  and  there  was  any  delay,  he  would  gener- 
ally order  us  to  pour  on  a  little  chloroform  to  reinforce  the 
ether.  I  have  never  seen  a  death  from  or  during  anaesthe- 
sia. The  nearest  fatal  case  I  ever  saw  was  from  ether,  in 
a  gunshot  wound  case  in  the  United  States  army  during 
the  Civil  War.  As  Agnew  said,  there  are  a  certain  num- 
ber of  cases  who  die  under  ether,  and  one  of  these  cases 
may  come  to  any  one  of  us  at  any  time,  and  we  cannot 
help  it.  The  consensus  of  opinion  among  surgeons  now  is  to 
use  ether,  because  it  has  been  shown  that  fewer  deaths  on  an 
average  occur  from  its  use  than  from  chloroform.  As  ether 
rather  tends  to  increase  blood-pressure  when  used  as  an  anaes- 
thetic, and  chloroform  tends  to  lower  it,  it  possibly  makes 

82 


FORTY   YEARS    IN   THE   MEDICAT.    PROFESSION 

chloroform  the  safer  remedy  in  ol)stetrical  cases,  especially 
where  there  are  convulsions,  and  because  pain  is  a  vasomotor 
stimulant.  In  such  cases  as  contracted  kidney,  accompanied 
by  hypertrophy  of  the  left  ventricle  of  the  heart,  where  we 
often  have  such  excessive  blood-pressure,  also  in  chronic 
bronchial  troubles,  as  in  old  short-neck  wheezers,  as  we  may 
call  them,  chloroform  may  be  safer.  Children  have,  as  a 
rule,  high  blood-pressure,  and  as  chloroform  is  dangerous, 
as  a  rule,  by  paralyzing  the  vasomotor  system,  therefore  we 
may  generally  give  it  to  children  with  great  safety.  These 
are  our  present  lights  on  the  subject.  However,  science  and 
scientific  experimenters  never  stand  still.  There  is  one  thing 
always  to  remember  about  chloroform,  it  is  more  obnoxious 
to  the  kidneys,  as  a  rule,  than  ether,  and  has  a  well-marked 
devitalizing  effect  on  all  nerve-tissue  of  whatever  grade. 
Again,  remember,  after  anaesthesia,  especially  prolonged  an- 
aesthesia, and  especially  in  neurotic  women,  we  often  have  a 
train  of  bad  symptoms  following,  that  may  take  months  of 
careful  treatment  to  rectify,  and  it  is  well  always  to  watch 
for  and  remember  such  symptoms  in  all  cases  after  surgical 
operations. 

There  are  two  proper  ways  to  give  an  anaesthetic :  either 
use  an  Allis  inhaler,  or  merely  pour  the  fluid  on  several  folds 
of  gauze;    this  method  cannot  be  excelled. 

Again,  remember,  after  the  use  of  ether  and  chloroform 
particularly,  we  may  have  pneumonia,  heart  troubles,  and 
other  circulatory  irregularities  come  on.  These  cases  occur 
most  frequently  after  pelvic  operations  and  after  operations 
on  the  tongue  and  parts  adjacent  thereto.  During  my  profes- 
sional life  I  have  seen  a  few  of  these  cases.  They  may 
amount  to  lobar  pneumonia  or  to  broncho-pneumonia,  and 
either  may  be  slight  or  grave.  Examine  your  patient  care- 
fully if  after  anaesthesia  he  presents  any  circulatory  trouble. 
Before  operations  on  the  parts  connected  with  the  mouth  too 
much  care  cannot  be  taken  to  render  the  mouth,  nose,  and 
all  near  parts  as  near  as  possible  absolutely  aseptic,  and  keep 
them  so,  for  secondary  infection  mav  readilv  occur,  and  we 

83 


FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

may  have  the  micrococcus  lanceolatus  and  the  streptococcus 
present  at  once.  It  is  important  in  all  cases  to  have  the  towels, 
inhalers,  or  whatever  may  be  used  in  anaesthesia  thoroughly 
aseptic.  There  is  another  condition  sometimes  coming  on 
after  anaesthesia,  especially  after  operations  on  nervous 
women.  It  may  come  at  once  or  be  deferred  for  some  hours, 
or  even  days.  The  patient  suddenly  becomes  greatly  de- 
pressed, with  great  oppression  of  the  breathing,  with  all  the 
symptoms  of  heart-failure.  There  are  no  signs  of  pneumo- 
nia or  other  inflammatory  troubles,  only  inability  to  get  a 
satisfactory  breath,  which  requires  prompt  attention  in  the 
way  of  heart  and  other  stimulants.  The  trouble  is  undoubt- 
edly of  neurotic  origin,  and  may  be  mistaken  for  pulmonary 
embolism,  which,  of  course,  might  possibly  occur  under  such 
conditions.  The  same  troubles  in  a  lesser  degree  sometimes 
come  on  during  or  after  alcoholic  intoxication. 

At  the  suggestion  of  Dr.  Norcross,  of  Philadelphia,  oxygen 
has  lately  been  administered  with  chloroform  with  reported 
good  effect.  Dr.  Thomas  S.  K.  Morton  has  lately  experi- 
mented largely  with  the  simultaneous  administration  of  ether 
and  oxygen,  by  an  ingenious  apparatus.  Also  the  petroleum 
ether  mixture  of  Schleich  is  just  coming  into  notice,  and  may 
prove  a  boon  to  suffering  humanity,  but  its  containing  chlo- 
roform has  so  far  been  an  objection.  Simpson,  Morton, 
Wells,  and  Jackson  are  dead,  but  the  great  work  they  did  in 
life  lives  and  grows  after  them. 

During  my  visit  to  Europe  I  travelled  generally  through 
Germany,  and  remained  long  enough,  particularly  in  Berlin, 
to  get  a  good  insight  into  medical  matters  and  the  medical 
schools.  Germany  was  then  brimful  of  glory  and  brimful  of 
sorrow,  for  she  had  just  emerged  from  a  successful  war, 
which  terminated  in  their  great  victory  at  Sadowa,  or  K6- 
niggratz,  as  the  battle  is  most  frequently  called,  over  the 
Austrians.  Soldiers  were  everywhere,  and  I  remember  well 
the  grand  appearance  they  made  on  review  and  during  their 
drills,  and  with  what  contempt  they  treated  those  not  in 
accord  with  them,  as  when  in  Hanover  the  elegant  palace  and 

84 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

grounds  of  the  poor  blind  King  William  were  utterly  given 
over  to  the  soldiers,  with  the  grand  apartments  of  the  first 
floor  given  to  the  cavalry  horses  as  stables. 

The  great  surgeon  of  Prussia  at  that  day  was  Bernhard 
von  Langenbeck,  then  in  his  prime  at  fifty-six  years  of  age. 
He  was  not  an  imposing-looking  man;  he  had  rather  a  weak 
face,  a  sort  of  so-called  jimber-jaw  face,  but  lie  was  a  great 
man,  and  lacked  neither  great  courage  nor  great  learning. 
He  was  the  greatest  surgical  pathologist  of  Europe,  and  was 
the  successor  of  the  great  Dieffenbach,  in  the  University  of 
Berlin.  He  had  been  doing  great  work  in  the  war,  great  mili- 
tary surgeon  that  he  was,  and  he  looked  almost  worn  out 
with  his  labors.  Von  Grafe,  the  oculist,  was  the  idol  of  Ber- 
lin in  all  circles,  and  in  his  short  life  probably  did  more  than 
any  man  who  had  lived  up  to  that  time  to  advance  everything 
pertaining  to  eye  troubles,  not  least  of  which,  by  any  means, 
were  his  researches  as  to  the  nature  and  treatment  of  glau- 
coma. Frerichs  was  one  of  the  leading  physicians  connected 
with  the  Berlin  schools,  and  is  now,  years  after  his  death,  well 
remembered  for  his  exhaustive  treatise  on  the  liver  and  its 
diseases.  Berlin  was  full  of  able  doctors,  but  they  had  hardly 
got  well  into  line  in  their  work,  everything  having  been  dis- 
organized by  the  war. 

Vienna  was  the  great  medical  centre  of  Europe  at  this  time 
outside  of  London  and  Paris,  and  was  undoubtedly  the  IMecca 
for  a  great  majority  of  students  coming  from  countries  for- 
eign to  Europe.  As  a  clinical  school  it  had  no  equal  then,  and 
has  surely  no  equal  to-day,  material  of  all  kinds  being  plenty, 
both  living  and  dead.  I  believe  there  are  phlegmatic  Germans 
in  Vienna  who  will  hire  out  to  a  doctor  and  allow  him  to  cut 
ofif  their  legs  for  experimental  purposes,  provided  they  be  paid 
well  for  their  suffering.  Among  the  great  surgeons  in  Vienna 
at  this  date  were  Schuh,  Dumreicher.  and  Pitha.  Among 
the  obstetricians  were  Professor  Karl  Braun.  celebrated  the 
world  over.  Professor  Spaeth,  and  Professor  Chiari,  both 
great  masters  and  teachers.  Among  the  oculists  were  Arlt, 
Jaeger,  and  Stellwag.     Among  the  physicians  was  Skoda, 

8s 


FORTY   YEARS    IN    THE    MEDICAL    PROFESSION 

without  doubt  the  greatest  diagnostician  of  his  day,  but  I 
never  looked  with  much  favor  upon  his  treatment,  for  really 
I  do  not  believe  Skoda  gave  much  thought  to  treatment  and 
had  little  faith  in  the  efficacy  of  remedies.  He  was  an  enthu- 
siast in  diagnosis,  but  not  practical  in  therapeutics.  Oppolzer 
and  Tiirk  were  great  all-round  physicians,  and  gave  great 
celebrity  to  the  Vienna  schools,  especially  the  former. 

I  cannot  close  this  brief  reference  to  the  Vienna  medical 
men  without  mentioning  the  most  celebrated  pathological 
anatomist  of  his  day,  Karl  Rokitansky.  He  was  rector  of  the 
University  of  Vienna,  was  worshipped  by  the  faculty  of 
Vienna,  and  was  justly  honored  by  scientists  the  world  over. 

My  visit  to  Germany  ended,  I  commenced  my  homeward 
journey,  and  left  Europe  with  all  its  wonders  in  science,  in 
arts,  and  in  culture,  thankful  for  what  I  had  seen  and  more 
than  thankful  for  what  I  had  learned.  More  than  that,  I  left 
it  more  than  ever  satisfied  with  my  own  country,  with  my 
own  people,  and  that  my  lot  had  been  cast  as  a  citizen  of  the 
United  States  of  America. 


86 


CHAPTER    V. 

Returned  from  Europe  and  Settled  in  New  Castle,  Delaware — Its  Pecu- 
liar Freedom  from  Certain  Diseases — The  Medical  Profession  in 
Delaware — Country  Doctors — A.  Conan  Doyle — Ian  Maclaren — 
Bacteriology  Forty  Years  Ago — Pathogenic  and  Other  Germs — 
Toxines — Immunity — Inflammation — Operations  Forty  Years  Ago 
and  their  Results — Asepsis — Antisepsis — Origin  of  Life — Sir  Joseph 
Lister — Obstetrics  and  Antisepsis — Hospital  Gangrene — A  Strange 
Coincidence — Surgery  away  from  the  Centres — Disinfection — Neces- 
sity of — Gonorrhoea — Bladder  Troubles — Syphilis — Eye  Troubles — 
Gynaecology — Proctor  Knott — Appendicitis — Radical  Cure  of  Hernia 
• — Intubation  and  Tracheotomy — Fractures  and  Dislocations — Instru- 
ments— Rontgen  Rays. 

After  having  returned  from  Europe,  for  reasons  personal 
to  myself,  and  which  I  have  no  cause  to  regret,  I  settled  in 
the  little  city  of  New  Castle,  Delaware,  a  town  of  about  five 
thousand  inhabitants.  I  only  speak  of  this  because  I  have 
found  a  very  peculiar  condition  existing  here,  in  the  territory 
covered  by  this  town,  as  to  its  condition  of  healthfulness. 
The  situation  is  on  the  Delaware  River  about  thirty  miles 
below  Philadelphia,  and  is  on  a  point  or  peninsula  jutting  out 
into  the  river,  with  a  fall  towards  the  river  sufficient  for 
natural  drainage.  The  rise  and  fall  of  the  tide  twice  in 
twenty-four  hours  is  about  six  feet,  and  the  tidal  rate  is  about 
four  miles  per  hour.  Whilst  the  town  originally  was  built 
on  a  slight  bluff,  above  and  below  the  town  are  lowlands, 
protected  by  substantial  banks  and  drained  by  tidal  sluices. 
These  sluices  and  banks  have  always  been  well  cared  for,  and 
have  given  good  clean  meadow-land.  The  point  I  wish  to 
note  is  this, — and  I  note  it  from  observation  of  over  thirty 
years  and  from  statistics  gathered  from  my  records  of  daily 
practice,  which  I  have  scrupulously  kept, — the  very  rare  oc- 
currence, comparatively,  on  this  little  point  of  land  on  which 
the  little  city  of  New  Castle  is  situated,  of  infectious,  conta- 
gious, zymotic,  or  microbic  diseases.     For  over  thirty  years. 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

with  very  little  let-up,  I  have  been  a  very  busy  man  in  the 
practice  of  medicine.  In  that  time  I  have  done  probably  as 
much  work  as  a  man  should  do,  and  among  my  patients  in 
this  town  (I  omit  all  cases  in  my  consultation  work  at  home 
or  abroad)  I  have  not  averaged  five  cases  each  year  of  croup- 
ous pneumonia.  I  mean  by  croupous  pneumonia  the  infec- 
tious inflammatory  disease,  where  the  diplococcus  pneumoniae 
is  probably  present,  coming  on  with  the  chill,  the  bounding 
pulse,  the  flushed  cheek,  high  temperature,  the  crepitant  rale, 
the  bloody  sputa,  the  rapid  breathing,  and  so  on,  as  the  case 
proceeds.  I  have  never  seen  epidemic  croupous  pneumonia 
here.  Epidemic  croupous  pneumonia  I  look  upon  as  a  con- 
tagious disease,  and  the  mortality  is  generally  high.  Non- 
specific broncho-pneumonia  and  capillary  bronchitis,  espe- 
cially among  the  young,  and  which  are  possibly  non-microbic 
and  non-contagious,  are  probably  as  common  here  as  in  other 
places  near  b3^  Now  for  the  apparent  reason.  The  peninsula 
on  which  New  Castle  is  situated  juts  out  into  the  river,  with 
lowlands  above  and  below  it.  The  banks  are  all  thoroughly 
washed  twice  each  twenty-four  hours  by  the  tides  of  the  Dela- 
ware River,  and  by  this  rise  and  fall  of  the  tides  a  system  of 
capillary  drainage  is  produced,  which  acts  on  the  whole  town 
site,  stagnation  is  prevented,  and  the  hosts  for  the  developing 
of  the  obnoxious  microbes  are  in  a  large  degree  wanting. 
Other  zymotic  diseases  are  rare  here,  and  have  been  rare, 
taking  thirty  years  past.  Even  malarial  fevers  have  never 
abounded  except  during  the  time  when  the  blanket  of  malaria 
was  over  the  whole  country  some  years  ago,  when  even  the 
hills  of  New  England  were  not  exempt.  I  have  never  seen 
scarlet  fever  seriously  epidemic  here,  except  upon  one  occa- 
sion in  over  thirty  years,  and  a  serious  epidemic  of  diphtheria 
has  prevailed  only  once,  and  that  when  in  October,  1878,  the 
great  tidal  wave  swept  the  shores  of  the  Delaware  and  carried 
away  the  river-banks  above  and  below  the  town.  These  re- 
mained down  until  the  following  June,  when  they  were  re- 
stored. Then  the  dead  fish  and  decaying  matter  in  general 
furnished  a  most  convenient  host  for  the  plants,  and  diphthe- 


FORTY    YIlARS    IN    THE    MEDICAL    PROFESSION 

ria  came  upon  us  in  vigorous  form.  This  cxcmiJtion  from 
zymotic  disease  extends  only  a  short  (hstance  in  the  country, 
below,  above,  and  back  of  the  tow^n,  and  as  we  travel  west  and 
southwest,  and  pass  the  water-shed  of  the  Delaware  and  ap- 
proach the  Chesapeake,  we  find,  especially,  croupous  pneu- 
monia, frequently  epidemic  and  often  fatal. 

Among-  professions  in  Delaware  the  medical  profession  has 
always  held  a  high  position,  and  its  members  have  always 
been  prominent  in  all  matters  pertaining  to  good  citizenship. 
The  Delaware  State  Medical  Society  was  founded  in  1788, 
and  to  this  day  its  organization  has  been  held  intact,  and  its 
place  among  like  societies  in  the  United  States  has  always 
been  recognized  as  among  the  foremost  and  most  zealous. 
In  times  gone  by  the  names  of  many  men  of  prominence  have 
been  enrolled  in  the  medical  profession,  and  their  descendants 
to-day  are  prominent  in  all  parts  of  the  country.  Among 
some  of  those  prominent  as  practitioners  in  Delaware  in  early 
times,  I  may  mention  the  names  of  Tilton,  Sykes,  Naudain, 
Clayton,  McCalmont,  McLane,  Lofland,  Morris,  Vaughn. 
Couper,  Thompson,  S.  H.  Black,  Askew,  Mitchell,  Merritt. 
Porter,  Bush,  C.  H.  Black,  Saulsbury,  Jump,  Hamilton, 
Whiteley,  Kane,  Colesberry,  Barr,  Lowber,  and  Clark.  Most 
of  these  men  were  what  we  are  accustomed  to  call  country 
practitioners.  By  country  practitioners  I  mean  men  prac- 
tising away  from  and  not  within  easy  reach  of  the  medical 
centres.  This  applied  in  their  day  more  than  it  does  now,  for 
communication  is  so  perfect  and  rapid  in  nearly  all  parts  of 
the  country  that  it  is  possible  for  nearly  all  to  keep  readily  in 
touch  with  all  centres  of  trade  and  business.  I  know  and 
have  known  many  of  these  so-called  country  doctors,  and 
among  them  are  many  strong  and  vigorous  men  in  both  mind 
and  body.  They  are  always  factors  in  their  neighborhood. 
Being  strong  men,  they  often  drift  away  from  pure  profes- 
sional work,  and  become  too  much  routine  practitioners.  This 
is  often  not  their  own  fault,  for,  being  available  men,  they 
are  often  drafted  into  politics  and  into  political  places  by  their 
fellow-citizens,  and  thus  in  many  cases  the  public,   whilst 

89 


FORTY   YEARS    IN   THE    MEDICAL    PROFESSION 

gaining  a  good  official,  loses  a  competent  and  faithful  physi- 
cian. It  would  be  much  better  if  physicians  working  in  iso- 
lated locations  would  take  up  some  by-study  which  would 
help  them  in  their  profession,  such  as  botany,  comparative 
anatomy,  scientific  farming,  or  horticulture,  which  combine 
so  much  of  nature  study,  rather  than  drift  off  into  politics,  or 
into  the  mere  routine  work  of  pill-giving  and  empirical  drug- 
ging- 

I  know  well  a  great  many  country  doctors,  and  I  know 
many  of  them  to  be  good  all-round  men,  fair  general  practi- 
tioners of  medicine,  good  diagnosticians,  some  very  good 
obstetricians,  and  some  very  good  every-day  surgeons;  I 
know  men  who  have  done  general  amputating;  I  know  men 
who  have  done  all  of  the  operations  in  obstetrics,  including 
Caesarean  section;  and  I  know  of  ovariotomy  having  been 
done  by  the  country  doctor,  and  successfully,  too.  These 
men,  like  our  city  friends,  have  their  own  troubles ;  they  have 
their  professional  jealousies,  their  little  tilts  with  one  another, 
their  troubles  with  and  from  the  neighborhood  gossips  and 
from  ungrateful  patients,  but  they  as  a  class  are  equal  to  all 
emergencies,  and  can  hold  their  own  with  the  best  of  God's 
creatures. 

A  little  story  of  A.  Conan  Doyle's  holds  up  to  nature  most 
admirably  the  feelings  and  the  engendered  jealousies  and 
rivalries  often  seen  when  anything  comes  between  the  head 
doctor  of  a  small  town  and  the  full  sway  he  has  been  accus- 
tomed to  hold  for  a  long  time  before.  I  cannot  recall  the 
name  of  the  story,  but  it  is  true  to  nature  and  abounds  in 
skilful  knowledge  of  human  nature.  A  new  doctor  comes  to 
town  and  puts  out  a  sign.  We  will  call  him  Dr.  A.  Smith. 
The  old  doctor  of  the  place  is  a  man  of  really  great  merit, 
and  is  somewhat  worried  over  the  outset  of  the  new  one.  He 
waits  for  the  new  one  to  call,  and  the  new  one  waits  for  the 
old  one  to  call.  They  do  not  meet,  but  the  old  doctor  soon 
finds  out  the  new  doctor  is  a  woman.  She  proves  to  be  a 
woman  of  talent  and  especially  well  prepared  from  hospital 
experience  to  do  general  surgery  and  eye  work,  and  soon 

90 


FORTY    YEARS    TN    T1[E    MEDICAL    PROFESSION 

makes  a  local  reputation  from  some  fortunate  cases,  'i'he  old 
doctor  has  still  never  met  her,  but  feels  that  he  is  losinpj  his 
pre-eminence  to  the  new  woman.  The  fj]Ji)ortunity  comes  for 
the  new  woman,  who  is  really  a  fine  character.  The  old  doc- 
tor meets  with  a  runaway  accident  and  serious  injury,  is  car- 
ried into  a  near-by  house,  and  the  first  doctor  found  and 
called  in  is  Dr.  A.  Smith.  Of  course  the  first  meeting  is 
somewhat  embarrassing,  but  Dr.  A.  Smith  goes  to  work  and 
at  once  shows  to  our  old  friend  she  is  no  novice,  but  a  really 
skilful  and  accomplished  surgeon.  Well,  Doyle  elaborates 
the  story  very  artfully.  The  case  goes  through  very  favora- 
bly, the  doctor  recovers,  and  the  two  become  inseparable  com- 
panions. Every  one  reading  the  story  at  this  point  makes  up 
his  mind  they  will  marry.  Doyle  brings  it  out  differently. 
Dr.  A.  Smith  soon  leaves  the  small  town,  goes  to  a  large  city, 
and  becomes  a  great  specialist.  Every  physician  should  read 
this  little  story,  and  see  how  "  one  touch  of  nature  makes  the 
whole  world  kin." 

Ian  Maclaren  says  he  has  often  been  asked  the  question, 
Was  there  ever  any  doctor  so  self-forgetful,  and  so  utterly 
Christian,  as  William  MacLure,  the  hero  of  his  "  Doctor  of 
the  Old  School"?  To  which  he  replied,  as  he  said,  on  his 
conscience,  not  one  man,  but  many,  in  Scotland  and  in  the 
South  Country.  Should  I  be  asked  the  same  question,  I 
should  answer,  on  my  conscience,  yes.  I  have  known  more 
than  one  William  MacLure  in  the  medical  profession.  No 
set  of  worthy  men  ever  had  a  greater  compliment  paid  them 
than  had  the  country  doctors  when  Ian  Maclaren  took  one 
of  them  as  the  hero  of  his  lovely  and  pathetic  story  of  "  A 
Doctor  of  the  Old  School." 

That  medicine  to-day  is  a  progressive  science  and  not  the 
empiricism  of  the  olden  times  is  shown  very  plainly  when  we 
review  the  course  of  surgery  in  the  last  forty  years.  Even 
during  this  short  time  surgery  has  advanced  from  a  mere 
empirical  art  to  true  scientific  methods.  The  surgeon  is  no 
longer  a  mere  mechanic,  but  must  be  truly  a  scientific  man  in 
all  that  the  name  implies.     The  great  advances  have  been  all 

91 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

along  the  line,  in  diagnosis,  in  manual  procedure,  in  technique, 
in  his  armamentarium,  and,  above  all,  in  the  magnificent  re- 
sults of  the  cases  treated. 

Forty  years  ago,  bacteriology  played  little  or  no  part  in 
surgical  diagnosis.  We  knew  little  of  the  saprophytic  or  of 
the  pathogenic  bacteria.  We  knew  little  of  the  habitat  of 
germs,  or  of  the  parasitic  nature  of  many  of  the  pathogenic 
germs,  or  that  some  could  live  in  both  dead  and  living  animal 
matter  and  some  in  dead  tissue  alone.  We  knew  little  of  the 
nature  of  germs,  of  their  life  history  and  of  their  require- 
ments for  existence.  We  knew  little  or  nothing  of  the  tem- 
perature required  for  their  growth  and  development,  or  of  the 
effect  of  sunshine  on  their  prosperity,  all  very  practical  points. 
Now  we  know  much  about  them.  We  knew  nothing  of  how 
bacteria  were  propagated,  nor  that  the  spores  were  much 
more  difficult  to  destroy  than  the  parent,  another  important 
point  in  practice.  Every  living  thing  generates  its  own  poi- 
son, and,  it  follows,  so  do  bacteria.  The  growth  of  the 
colony  is  limited  by  the  poison  it  generates,  and  hence  we 
have  toxines.  Some  of  these  toxines  are  fermentative,  or 
ptomaines  so  called,  which  are  cadaveric  alkaloids  and  very 
poisonous  to  animal  life,  as  most  of  us  in  the  course  of  a  life- 
time know  from  bitter  experience.  Ice-cream  poison  cases, 
cream-puff  poison  cases,  fish  poison  cases,  are  the  most  promi- 
nent. Others  of  these  toxines  are  called  toxalbumins,  and  are 
more  or  less  synonymous  with  the  ptomaines  as  to  results. 
Bacteriology  has  advanced  to  such  a  point  as  to  have  become 
a  great  life-study  and  work  within  itself,  and  the  different 
germs  can  be  grown  like  potatoes,  and  their  life  history  can 
be  studied  with  absolute  exactness  and  detail  from  laboratory 
cultures,  and  again  by  inoculation  into  the  lower  animal  life; 
and  Koch's  law  requires  this  culture  growth  and  reproduction 
of  the  original  through  inoculation  into  the  lower  animal. 

By  this  study  of  the  life  history  of  germs  we  find  how  they 
infest  the  body,  how  they  enter,  whether  by  skin  or  mucous 
membrane,  or  otherwise,  or  by  the  mouth  only,  as  the  comma 
bacillus  of  cholera.    We  have  also  learned  how  they  are  elimi- 

92 


FORTY    YEARS    IN   THE    MEDICAL    PROFESSION 

nated  or  excreted  from  the  body,  and  also  the  symptoms  they 
produce,  and  the  resistance  the  animal  body  fjffers  to  them, 
being  the  difference  between  health  and  disease,  for  none  of 
us  know  how  many  thousands  of  millions  are  bustling  about 
us  and  lurking  in  our  throats  and  other  parts  of  our  bodies, 
the  fortunate  escaping  all  ill  effects,  the  unfortunate  succumb- 
ing to  many  of  the  ills  "  flesh  is  heir  to."  After  all,  we  are 
all  exposed;  it  all  depends  upon  the  soil  the  germs  light  on; 
those  that  fall  on,  to  them,  good  soil  carry  misery  and  death 
in  their  train,  whilst  those  that  fall  on  stony  ground  perish, 
and  individual  life  goes  on  with  unconcern ;  immune,  we  say, 
the  subject  is. 

Now,  this  question  of  immunity  is  a  burning  question,  and 
the  production  of  artificial  immunity  is  in  the  direction  of  the 
great  strides  being  made  to-day  in  bacteriology,  and  sufficient 
has  been  done  in  diphtheria,  not  mentioning  hydrophobia,  an- 
thrax, tetanus,  and  other  diseases,  to  have  already  written  one 
of  the  most  brilliant  pages  in  the  history  of  medicine.  Here 
again  practically  every  living  thing  generates  its  own  poison, 
for  the  great  Pasteur  took  the  opposite  course  to  antitoxins 
when  he  recommended  the  starting  of  a  deadly  epidemic  by 
inoculation  of  a  few  individual  specimens  with  a  toxine  or 
disease  to  rid  Australia  of  her  rabbit  pest.  The  great  advance 
made  in  bacteriology  was  in  the  staining  of  the  germs  to  be 
examined,  and  has  made  possible  the  great  advances  made  in 
examining  by  the  microscope  many  of  the  pathogenic  germs. 
Take,  as  an  example,  Ziehl's  solution  for  coloring  tubercle 
bacilli,  following  the  usual  technique.  The  bacilli  that  most 
concern  the  surgeon  are  those  mostly  concerned  in  suppura- 
tion of  some  kind, — the  staphylococci,  comprising  pyogenes 
aureus  and  pyogenes  albus ;  the  streptococci,  the  gonococcus, 
the  bacillus  coli  communis,  or  the  bacterium  coli  commune. 
The  bacillus  pyocyaneus  is  found  in  the  greenish  pus — the 
pus  we  see,  or  rather  formerly  saw,  for  \ve  aim  not  to  have 
pus  now  about  wounds — coming  from  wounds  profusely 
when  granulations  are  just  commencing,  causing  renewed 
vitalit}^  in  the  condition,  creamy,  laudable  pus.     The  Klebs- 

93 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Loeffler  bacillus,  the  germ  of  diphtheria,  also  concerns  the 
surgeon.  The  bacillus  tuberculosis  is  a  most  important  germ 
which  the  surgeon  now  has  to  know  of  and  deal  with,  which 
only  a  few  years  ago  he  did  not  dream  of  as  a  cause  of  the 
troubles  he  was  endeavoring  to  relieve.  Especially  is  this 
the  case  in  bone  surgery.  Also  the  germs  of  anthrax,  hydro- 
phobia, glanders,  tetanus,  and  others  concern  him. 

Forty  years  ago,  in  any  medical  school,  upon  the  advent  of 
a  new  professor,  his  standing  in  the  profession  and  his  ability 
to  fill  the  position  was  generally  measured  by  his  views  on 
inflammation.  Even  at  this  day  there  was  little  solid  knowl- 
edge, but  it  was  usually  looked  upon  as  a  fire  to  be  quenched, 
as  it  were,  by  water ;  for  water,  and  little  of  it,  was  about  the 
diet  presented  under  the  antiphlogistic  system,  and  this  was 
freely  purged  away,  although  it  was  about  this  time  that  Dr. 
Tod  began  his  advocacy  of  opposition  to  the  extreme  antiphlo- 
gistic school,  urged  on,  perhaps,  by  the  well-known  views  and 
practice  of  Robert  Graves,  the  great  Dublin  physician;  and 
probably  both  were  in  a  measure  followers  of  Cullen,  who 
was  among  the  first  to  discountenance  the  abuse  of  venesec- 
tion. 

In  looking  over  an  old  book  on  surgery  published  nearly 
fifty  years  ago,  I  read,  "  The  operator  must  bear  in  mind  the 
great  principles  of  all  sound  practice, — viz.,  the  treatment  of 
inflammation.  Is  the  wound  to  heal  by  first  intention  or  by 
granulation?  Is  the  object  of  the  operation  to  be  attained  by 
exciting  inflammation,  or  will  its  development  destroy  the 
result?  Is  the  action  to  proceed  simply  to  the  effusion  of 
lymph,  or  to  suppuration?"  One  man  is  quoted  as  always 
purging  his  patients  during  the  after-treatment  of  capital 
operation  to  prevent  inflammation.  Many  years  ago  Pro- 
fessor S.  D.  Gross  wrote  to  me  in  regard  to  a  case  that  had 
not  gone  on  well,  using  at  the  end  of  his  letter  these  words : 
"  God  knows  surgery  is  not  a  sinecure,  but  a  most  corroding, 
soul-disturbing  profession."  Were  he  alive  to-day,  with  the 
use  of  modern  methods,  his  case  would  have  gone  on  well, 
and  he  would  not  have  needed  to  pen  such  pessimistic  senti- 

94 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

ments;  althoug-h,  in  the  main,  they  still  hf)l(l  true,  for  surgery 
doubtless  is,  with  all  the  help  given  it  by  modern  methods 
and  modern  ideas,  "  not  a  sinecure,  but  a  most  corroding, 
soul-disturbing  profession." 

Thirty-five  years  ago  Gross's  idea  of  inilammation  was  that 
in  considering  it,  it  was  necessary,  first,  to  consider  the  nature 
of  the  capillaries  in  which  the  morbid  action  is  mainly  carried  ; 
secondly,  the  character  of  the  blood  which  is  so  singularly 
changed  in  inflammation ;  thirdly,  the  part  played  by  the 
nervous  system ;  and  fourthly,  the  condition  of  the  tissues  at 
the  seat  of  disease.  This  definition  conveys  the  advanced 
ideas  of  that  time,  and  really  throws  no  light  on  the  subject; 
and  to  show  this  is  why  I  refer  to  it.  He  speaks  of  changes 
wrought  in  the  blood,  etc.,  its  color,  arrangement  of  globules, 
bufify  coat,  etc.,  the  white  and  red  corpuscles  stopping  the 
capillaries  and  producing  stagnation,  and  so  on  to  the  prod- 
ucts of  inflammation.  He  also  thought  the  nerves  played  an 
important  part  in  inflammation.  There  was  no  hint  yet  in 
those  days  of  zymosis,  although  the  germ  theory  of  disease 
had  been  talked  about.  He  did  not  think  inflammation  was 
necessarily  attended  by  suppuration,  as  Miller,  the  Edinburgh 
surgeon,  did.  Gross  thought  inflammation,  as  a  rule,  should 
be  treated  by  the  lancet,  low  diet,  mercury,  blisters,  and  all 
the  antiphlogistic  remedies ;  yet  he  said  there  was  a  period  in 
almost  every  attack  of  severe  disease  when  the  patient  would 
need  brandy,  wine,  quinine,  and  nutritious  food. 

I  have  quoted  Gross  at  length  as  one  of  the  great  authori- 
ties of  the  time  I  refer  to,  in  order  to  contrast  his  ideas  with 
those  of  to-day,  where  what  we  know  of  inflammation  is  not 
mere  guesswork  and  empiricism,  but  approaches  the  exact 
results  of  scientific  work.  The  surgeon  to-day,  as  of  old, 
recognizes  inflammation  by  pain,  redness,  swelling,  heat,  and 
impaired  function;  and  by  the  results  of  microscopical  ex- 
amination he  gets  definite  information  as  to  its  cause,  etc. 
It  may  be  said  that  he  recognizes  bacteria,  or  rather,  more 
broadly,  microbes,  as  the  cause  of  all  inflammation,  be  the 
original  cause  what  it  may,  whether  accident,   disease,   or 

95 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

injury.  There  may  be  exceptions  here,  as  in  such  a  disease 
as  gout,  but  in  this  day  of  wonderful  discovery  we  are  not 
even  sure  of  that.  Here,  then,  is  absokite  tangible  evidence 
as  to  the  cause  of  inflammation,  the  great  bugbear  of  forty 
years  ago,  when  all  definitions  were  mere  guesswork,  for 
the  reason  that  scarcely  anything  was  known  of  the  true 
cause  of  the  condition.  Oh,  how  the  great  men  of  that  day 
floundered  in  the  mire  of  ignorance !  Yet  the  new  professor 
just  called  to  his  chair  was  usually  gauged  as  to  his  ability 
by  his  lecture  on  inflammation.  The  improvements  in  micro- 
scopes and  their  collaterals,  together  with  the  improved  meth- 
ods and  technique,  have  done  everything  for  the  surgeon,  and 
when  we  come  to  add  to  this  the  practical  application  of 
knowledge  thus  attained  by  such  men  as  Pasteur,  Cohnheim, 
Senn,  Park,  Tyndall,  and  Lister,  we  commence  to  see  the  why 
and  the  wherefore  of  the  great  march  of  surgery,  from  the 
ranks  of  an  empirical  art  to  the  broader  domain  of  a  great 
science. 

When  I  was  a  hospital  resident  the  surgeon  came  in  from 
the  street,  took  off  his  gloves,  probably  his  coat,  then  his 
shirt-cuffs,  rolled  up  his  sleeves,  and  was  ready  for  work.  If 
he  washed  his  hands  as  a  preliminary,  it  was  for  his  own 
comfort,  not  from  any  thought  of  saving  his  patient  from  any 
contamination ;  nor  did  he  give  a  thought  to  what  case  he  had 
come  from,  as  to  whether  or  not  he  might  carry  trouble  to 
the  operatee.  The  assistants  came  from  any  ward  they  hap- 
pened at  the  time  to  be  in,  and  prepared  themselves  about  as 
the  chief  had  done  before  them,  and  took  about  the  same  pre- 
cautions, and  these  precautions  aimed  chiefly  at  their  own 
convenience.  In  the  well-appointed  hospital  utensils  were  of 
course  kept  scrupulously  clean  and  neat,  but  there  was  no 
attempt  at  sterilization  or  thought  of  germs.  The  instru- 
ments were  spread  on  a  tray,  fresh  from  their  receptacles, 
looking  clean,  from  the  washing  and  wiping  after  their  last 
use.  The  dressings  were  simple, — lint,  bandages,  and  proba- 
bly a  jar  of  cerate,  and  adhesive  plaster.  If  the  case  was  a 
ward  case,  the  parts  to  be  involved  in  the  operation  were  gen- 

96 


FORTY   YEARS    IN   THE   MEDICAL    PROFESSION 

erally  shaved  and  washed  the  (hiy  hefore.  If  the  case  was  a 
recent  accident  just  in,  and  sliock  had  passed  off,  the  patient 
was  at  once  taken  to  the  operating-room,  placed  on  the  table, 
and  etherized,  and  then  and  there  his  clothing,  at  least  the 
part  involved,  was  removed,  the  parts  were  shaved  and  washed 
with  soap  and  warm  water,  and  he  was  ready  for  the  sur- 
geon. 

The  operation  completed,  the  dressing  was  simple.  For  an 
amputation  of  the  leg  below  the  knee,  for  instance,  sutures, 
adhesive  straps,  a  Maltese  cross  of  sheet  lint,  covered  with 
simple  cerate  over  the  stump,  and  retained  by  a  simple  roller 
of  cotton  cloth.  Drainage  was  seldom  or  never  used.  This 
was  usually  removed  within  the  first  forty-eight  hours,  and 
the  case  treated  as  occasion  required  to  the  end.  Suppuration 
was  always  very  free ;  pus  cavities  often  formed ;  erysipelas, 
secondary  hemorrhage,  or  gangrene  might  come  at  any  time, 
depending  much  on  the  condition  of  the  patient  or  of  his  en- 
vironment. 

In  the  Philadelphia  hospitals,  especially  in  the  Pennsylva- 
nia Hospital,  the  great  accident  hospital  of  that  day,  erysipe- 
las, with  all  its  attendant  surgical  horrors,  was  common  in  the 
winter  months,  especially  in  the  months  of  February  and 
March.  The  cause  of  this  is  apparent :  the  house  closed 
against  inclement  weather  confined  the  germs  and  checked 
them  from  floating  out  on  the  air  currents,  as  they  did  when 
doors  and  windows  were  open.  Now  this  has  all  been  changed 
by  methods  so  simple  and  so  perfect  as  to  make  us  stand 
amazed  that  no  one  had  ever  perfected  it  before.  I  say  per- 
fected, for  many  before  the  days  of  Lister  appeared  to  have 
inklings  of  the  germ  theory  of  disease  and  of  their  ill  effects 
in  wounds  of  all  kinds,  whether  surgical  or  accidental.  For 
asepsis  and  antisepsis,  the  credit  of  their  development  and  the 
first  rules  of  application  is  universally  accorded  to  Sir  Joseph 
Lister,  now  Lord  Lister,  and  no  great  title  was  ever  better 
earned  or  more  worthily  bestowed.  Other  great  scientific 
experimenters  are  almost  equally  worthy,  among  them  the 
great  Pasteur,  Tyndall,  Schwam,  Koch,  Theodor  Billroth, 
7  97 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

and  others,  all  uncrowned  kings  among  men,  worthy,  living 
or  dead,  of  the  homage  of  all  mankind. 

Up  to  within  recent  years  we  were  all  at  sea  in  regard  to 
the  origin  of  life,  of  the  ultimate  element,  and  the  scientific 
man,  the  theologian,  the  materialist,  the  Deist,  and  the  infidel 
all  had  their  theories,  and  some  men  thought  to  be  among 
the  ablest  among  those  living,  had  full  faith  in  spontaneous 
generation.  This  theory  at  last  was  completely  nullified  by 
the  grand  work,  especially  of  Pasteur  and  Tyndall,  and  that 
within  thirty  years.  As  to  the  origin  of  life,  according  to 
Virchow,  science  can  only  recognize  one  cause,  previous  life. 
"  Omnis  cellula  e  cellula,"  "  Omne  vivum  ex  vivo,"  are  his 
declarations.  Spontaneous  generation  has  no  claims  for  him. 
Creation  does  not  satisfy  him.  His  idea  of  the  origin  of  life 
is  life  itself;  beyond  this  he  cannot  lift  the  veil.  Without 
saying  so,  whatever  is  beyond  he  leaves  to  the  discussions  of 
theology  and  theologians. 

The  recognition  of  the  germ  theory  of  disease,  of  the  lower 
orders  of  life  as  the  cause  of  disease,  of  the  parasitic  nature 
of  all  fermentative  or  zymotic  diseases  really  brought  about 
the  recognition  of  antisepsis  in  surgery,  and  the  recognition 
of  antisepsis  brought  about  the  recognition  of  the  necessity 
for  the  aseptic  condition — of  asepsis.  Lister's  first  practical 
work  was  in  the  nature  of  antisepsis.  He  taught  the  necessity 
of  having  everything  made  clean  about  operator,  assistants, 
the  patient,  the  instruments,  the  dressings,  and  the  environ- 
ment, and,  in  addition,  he  impregnated  the  atmosphere,  the 
operator,  the  patient,  the  assistants,  and  everything  concerned 
with  germicidal  sprays.  I  will  never  forget  my  first  experi- 
ence. It  was  at  the  Pennsylvania  Hospital.  Dr.  Thomas  G. 
Morton,  with  Agnew  and  Hunt,  was  making  an  ovariotomy. 
The  steam-atomizer  was  started  early  in  the  preparations  with 
a  carbolic  acid  solution,  and  when  all  was  finished  I  do  not 
know  that  I  could  say  who  had  been  in  most  danger,  patient, 
operator,  or  lookers-on.  It  was  a  most  unpleasant  experience 
in  every  way,  but  the  patient  developed  no  septic  symptoms, 
nor  did  anybody  suffer  more  than  temporary  inconvenience. 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

As  time  passed  on  it  was  soon  found  that  all  these  formali- 
ties were  not  necessary,  that  it  was  not  air  contact,  bnt  mate- 
rial contact  with  wounds  that  was  most  to  be  dreaded;  in 
other  words,  render  everything — operator,  patient,  assistants, 
dressings,  brushes,  and  the  general  environment — aseptic  be- 
fore doing  the  operation.  Instead  of  germicidal  poisons  for 
instruments,  dressings,  etc.,  we  rely  on  steam,  boiling  water, 
and  formaldehyde  solutions,  and  for  patient,  operator,  and 
assistants,  scrubbing,  scrubbing,  scrubbing,  with  water,  soap, 
ether,  and  formaldehyde  solutions,  until  all  living  parts  to 
come  in  contact  with  living  parts  are  thoroughly  and  abso- 
lutely aseptic.  I  have  amputated  a  thigh,  using  only  two 
per  cent,  formaldehyde  solution,  and  had  best  results  and 
no  pus.  There  are  some  glaring  defects  yet  that  I  am  sure 
we  must  remedy  before  we  get  perfect  asepsis.  It  has  been 
found  that  in  coughing  and  sneezing  over  an  agar  plate, 
and  then  examining  after  a  proper  interval,  colonies  of  bac- 
teria were  developed.  Here  is  a  source  of  infection  from  the 
surgeon  or  assistants.  To  remedy  this  all  must  wear  gauze 
masks,  and  the  coming  surgeon  zvill  zvcar  them.  The  coming 
surgeon  will  also  wear  gloves  of  some  kind,  of  a  kind  that  will 
least  blunt  his  sense  of  touch.  These  will  be  especially  neces- 
sary in  military  surgery  and  where  asepsis  cannot  be  rigidly 
practised.  Think  of  the  changes  wrought  by  these  methods. 
They  can  only  be  appreciated  by  those  who  had  experience 
in  large  hospitals  or  in  military  life,  or  in  obstetrical  practice 
previous  to  twenty-five  years  ago. 

Before  asepsis  had  been  so  thoroughly  impressed  on  obste- 
tricians puerperal  fever  often  raged  in  communities  for 
months,  and  the  mortality  often  became  fearful.  In  large 
cities  like  Philadelphia  and  New  York  it  was  very  often  epi- 
demic, and  sporadic  cases  were  always  occurring,  and  made 
the  life  of  the  obstetrician  one  of  dread  and  horror,  and  the 
safety  of  all  lying-in  women  was  in  great  jeopardy.  Whilst 
many  medical  men  recognized  its  contagiousness,  and  de- 
clined other  cases  whilst  attending  it,  others  denied  its  conta- 
giousness and,  we  now  well  know,  spread  it  far  and  wide  as 

99 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

they  passed  from  case  to  case.  To-day  traumatic  erysipe- 
las, if  there  is  another  kind,  is  comparatively  unknown,  and 
the  results  in  compound  fractures  are  simply  miraculous, 
and  operations  never  dreamed  of  thirty  years  ago  are  now 
performed  with  impunity  and  great  success.  Antiseptics 
have  also  invaded  the  domain  of  the  skin  specialist,  but 
it  is  in  military  surgery  where  asepsis  and  antisepsis  are 
bound  to  show  their  great  efficiency,  in  the  prevention  of 
much  cruel  suffering  and  in  the  saving  of  thousands  of 
lives.  Those  of  us  who  had  experience  in  our  late  Civil 
War,  and  those  who  saw  the  slaughter  wrought  by  gan- 
grene, secondary  hemorrhage,  and  allied  horrors,  now  en- 
tirely preventable  by  antiseptic  methods,  surely  can  appreciate 
the  great  work  done  by  Lister  and  his  followers,  and  can 
never  cease  to  thank  God  for  giving  such  instrumentalities  to 
man  for  the  alleviating  of  human  suffering  and  the  lessening 
of  human  anguish.  The  great  distress  in  war  in  those  days 
was  not  at  the  front  in  the  excitement  of  battle,  nor  during 
the  excitement  of  the  primary  operations  on  the  field  during 
and  after  the  battles.  The  horrors  came  generally  a  few  days 
afterwards,  in  the  rear,  when  sloughing,  gangrene,  and  sec- 
ondary hemorrhage  became  rife  and  made  life  a  burden  not 
only  to  the  poor  patients,  but  to  the  surgeons  and  all  those 
engaged  in  helping  them. 

The  remedies  used  for  gangrene  and  its  allied  troubles  were 
numerous,  and  were  limited  in  number  only  by  the  names  in 
the  pharmacopoeia.  Bromine  was  the  great  remedy.  The 
dead  parts  were  cut  away  and  the  bromine  applied  with  a 
glass  rod  to  the  sound  tissue,  which  it  destroyed  by  oxidation, 
and  thus  had  germicidal  action.  Proper  aseptic  precautions 
were  not  thoroughly  taken,  and  little  headway,  as  a  rule,  was 
made  against  the  disease,  and  reamputations,  of  course,  were 
generally  followed  by  gangrene  in  the  new  stump.  I  used 
Monsel's  salt,  the  powdered  subsulphate  of  iron,  very  freely, 
and  thought  I  got  better  results  than  from  bromine. 

When  I  think  of  these  cases  of  hospital  gangrene,  second- 
ary hemorrhage,  and  the  like,  the  most  affecting  scene  I  ever 

lOO 


FORTY    YEARS    IN    THE    MEDICAL    PROEI-ISSION 

witnessed  always  comes  up  l)efore  me,  and  there  is  a  very 
strange  coincidence  connected  witli  it.  A  young  officer,  an 
only  son,  a  thoroughly  fine  and  noble  fellow  from  one  of  the 
New  England  regiments,  was  fatally  wounded  in  the  spine 
during  one  of  the  engagements  in  Grant's  Wilderness  cam- 
paign. He  was  brought  to  the  rear,  and  I  had  charge  of  him 
in  one  of  the  hos]:>itals.  I  became  interested  in  him.  As  he 
lingered  on,  his  mother  and  sister,  very  nice  people,  came 
from  their  home  to  see  him  and  do  what  they  could  to  help 
him.  He  lasted  only  a  short  time,  in  great  suffering.  On  a 
beautiful,  warm,  moonlight  evening  he  was  rapidly  sinking, 
his  distressed  mother  and  sister  hovering  over  him,  when 
suddenly,  without  any  collusion,  a  near-by  band  slowly  and 
softly  struck  up  the  dirge  very  familiar  in  those  days,  which 
runs  about  as  follows : 

"  Soon  with  angels  I'll  be  inarching. 
With  bright  laurels  on  my  brow ; 
I  have  for  my  country  fallen, 
Who  will  care  for  mother  now  ?" 

Just  as  the  last  notes  died  away, — "  Who  will  care  for 
mother  now?" — his  soul  passed  to  the  great  beyond,  and  his 
terrible  sufferings  ceased  forever.  Of  all  the  sad  and  pathetic 
scenes  I  have  witnessed,  this  was  the  saddest  and  most  pa- 
thetic. Such  is  war,  which  now  again  after  many  years  is 
coming  towards  us  with  rapid  strides,  and  again  just  such  sad 
and  pathetic  scenes  may  be  witnessed  in  the  land.  There  is 
one  consolation,  sufifering  will  be  much  less  among  the  sick 
and  wounded,  there  will  be  little  or  no  gangrene  and  second- 
ary hemorrhage,  and  every  soldier  will  be,  or  should  be,  pro- 
vided with  dressings  with  which  to  bind  up  his  own  or  his 
comrade's  wounds  temporarily,  until  the  surgeon  shall  get 
him  and  bring  to  bear  his  skill,  aided  by  modern  methods  and 
modern  ideas.    Thus  the  great  world  moves  on. 

Since  the  introduction  of  antisepsis  and  asepsis  the  pre- 
paring the  environment  of  the  patient  has  become  equally  as 
important  as  preparing  the  body  of  the  patient.    This  is  easy 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

to  accomplish  in  the  well-constructed  modern  hospital,  where 
everything-  has  been  made  to  conform  to  this  end.  In  a  pri- 
vate house  this  is  much  more  difficult,  often  impossible,  and 
even  when  attempted  the  whole  scheme  may  be  spoiled  by 
some  thoughtless  member  of  the  family  invading  the  apart- 
ment with  untidy  dress,  or  fresh  from  some  deadly  infection. 
For  this  reason  I  do  not  hesitate  to  advise  patients  who  are  to 
undergo  operations  of  almost  any  kind  to  seek  a  well-regu- 
lated hospital,  where  they  may  obtain  the  best  surgical  advice 
and  take  quarters  suited  to  their  purse,  either  in  the  wards  or 
in  private  apartments,  where  they  may  obtain  comforts  equal 
to  our  best  hotels,  and  where  at  a  moment's  notice  good  sur- 
gical service  may  be  present  for  any  emergency. 

I  have  done  a  good  deal  of  surgery  during  my  professional 
career,  but  in  practice  away  from  the  centres  it  is  hard  and 
exacting  work.  Since  the  advent  of  the  trained  nurse  it  has 
improved  somewhat,  but  when  a  man  does  a  capital  operation 
he  is  apt  to  be  disturbed  at  any  moment  and  very  often,  day 
or  night,  during  the  first  day  or  two,  for  if  even  a  drop  of 
blood  appears  on  the  dressing  the  doctor  is  summoned  at  once, 
and  to  a  man  weary  already  from  overwork  this  anxiety  be- 
comes almost  unbearable.  Under  all  circumstances,  I  believe 
it  better  for  the  patient  and  for  the  doctor  to  send  all  but 
emergency  surgical  cases  to  a  well-regulated  hospital.  Hos- 
pital work  is  an  absolute  necessity  for  a  successful  surgical 
career.  This  is  the  very  opposite  to  the  advice  I  should  have 
given  thirty  years  ago.  Then  the  average  hospital  was  a 
pest-house  to  be  avoided  in  all  cases  where  operative  inter- 
ference was  required.  So  much  for  the  evolution  of  science 
in  germ  destruction. 

Disinfection  is  now  carried  on  to  include  the  whole  town 
under  the  supervision  of  boards  of  health,  and  the  technique 
is  applied  to  houses  and  their  surroundings,  to  the  sick-room, 
utensils,  receptacles  for  sputa  especially,  and  for  the  alvine 
evacuations.  Indeed,  the  disinfecting  organization  should 
doubtless  always  follow  the  doctor.  Under  modern  methods 
and  care  the  vile  spitting  habit  is  being  much  curtailed,  for, 

102 


FORTY    YEARS    TN    TFTE    MEDICAL    PROFESSION 

besides  its  filthiness,  it  is  a  j,n-c<it  factor  doubtless  in  spreading 
disease.  Tbe  whole  tendency  t(j  disinfect  is  spreading,  but 
not  any  too  rapidly.  All  places  of  resort  should  be  regularly 
made  as  nearly  aseptic  as  possible;  so  shoukl  all  public  con- 
veyances, especially  the  sleeping-apartments  of  cars  and  boats, 
churches,  hotels,  schools,  especially  water-closets  and  such 
apartments,  for  undoubtedly  the  most  loathsome  diseases  may 
be  induced  by  contact  in  such  places.  School-books  and  library 
books  should  be  regularly  disinfected,  and  there  is  no  doubt 
in  the  world  that  more  care  should  be  exercised  by  barbers  as 
to  absolute  cleanliness,  and  all  their  tools  should  be  sterilized 
each  time  before  use.  All  such  rules  apply  with  equal  force 
to  dentists,  and,  of  course,  to  physicians  too,  whether  caring 
for  man  or  beast.  There  is  one  thing  that  should  be  carefully 
avoided, — never  use  a  catheter,  speculum,  or  instrument  of 
any  kind  in  a  cavity  lined  by  mucous  membrane  without  first 
thoroughly  sterilizing  it.  This  is  readily  done  by  boiling 
glass  and  metal  instruments,  and  if  made  of  rubber,  soak 
them  from  ten  to  fifteen  minutes  in  one  to  one  thousand 
bichloride  solution  or  in  a  two  per  cent,  formaldehyde  so- 
lution and  then  thoroughly  wash  with  water  that  has  been 
boiled  at  least  twenty  minutes.  The  surgeon's  hands  also,  of 
course,  should  be  sterilized,  as  should  the  lubricant  used,  and 
also  the  organs  of  the  patient  and  their  surroundings.  These 
rules  should  apply  to  both  males  and  females.  There  is  a 
formalin  sterilizer  for  instruments  and  all  dressings  now  on 
the  market  which  is  simple,  cheap,  and  effective.  The  forma- 
Hn  is  put  up  in  solid  tablets,  and  a  simple  lamp  furnishes  the 
heat.  You  will  thus  avoid  cystitis  and  other  horrors  in  your 
patients.  Physicians  should  protest  to  patients  against  many 
of  the  habits  characteristic  of  human  beings,  such  as  rubbing 
the  eyes  with  the  unprotected  fingers,  for  no  man  knows  when 
he  touches  a  door-knob,  for  instance,  but  that  some  one  before 
him  may  have  left  the  gonococcus  or  some  vile  germ  as  a 
parting  legacy  to  closing  the  door,  and  a  gonorrhoeal  oph- 
thalmia may  follow  to  an  innocent  victim.  The  possibility  of 
such  accidents  by  some  such  means  should  be  instilled  into 

103 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

all,  and  many  a  sorry  victim  may  be  saved  from  all  the  hor- 
rors of  syphilitic  and  other  infections.  The  hands  of  every 
man,  woman,  and  child  should  be  sterilized  daily.  Cleanli- 
ness should  be  taught  to  all  and  practised  by  all.  "  Cleanli- 
ness is  next  to  godliness,"  and  self-preservation,  the  first  law 
of  nature,  is  the  coming  great  factor  in  the  carrying  out  of 
this  proverb.  The  scales  are  falling  from  the  eyes  of  man ; 
science  is  pointing  the  way;  he  begins  to  see  that,  living  in 
filth,  he,  like  all  living  beings,  generates  his  own  poison,  and 
that  the  philosophy  of  rational  existence  is  wash,  wash,  wash, 
scrub,  scrub,  scrub.  Instilling  such  methods  into  his  patients, 
the  physician  becomes  what  he  should  be,  a  public  teacher, 
and  thus  becomes  more  and  more  than  he  even  now  is,  a  public 
benefactor. 

As  I  look  forward  to  the  coming  branch  of  the  profession 
which  shall  bestow  on  mankind  its  greatest  benefits,  to  that 
branch  which  shall  shed  its  most  brilliant  lustre  upon  the 
world  at  large,  I  see  always  looming  up  before  me,  before  all 
others,  the  one  great  light, — the  forerunners  of  which  are 
antisepsis,  asepsis,  general  technique,  and  absolute  cleanliness, 
— the  coming  grand  practical  work,  preventive  medicine.  As 
to  antisepsis  and  asepsis  in  obstetrics,  they  are  of  great  im- 
portance, or  rather,  I  will  say,  absolute  care  and  cleanliness 
on  the  part  of  physician,  patient,  nurse,  and  all  the  help 
around  the  woman  and  the  entire  inorganic  environment 
should  be  scrupulously  clean,  and  kept  scrupulously  clean, 
during  the  labor,  and  the  whole  lying-in,  not  forgetting  the 
child,  both  for  its  own  sake  and  for  the  mother's.  If  we  have 
sufficient  warning  of  the  case,  the  apartment  should  be  pre- 
pared as  for  a  surgical  operation,  and  all  articles  to  be  used 
during  labor  should  be  kept  in  this  room,  first  having  been 
sterilized  by  heat,  wet  or  dry.  When  labor  begins  the  patient 
should  be  absolutely  cleansed  and  dressed  by  the  nurse,  having 
first  cleansed  herself,  and  no  other  unprepared  person  should 
approach  the  patient  during  her  labor.  When  the  doctor  ar- 
rives he  should  wash  up  thoroughly,  and  doubtless  should 
wear  a  clean  sterilized  linen  overall  gown  and  rubber  gloves, 

104 


FORTY    YI-ARS    IN    TJl)-:    MEDICAL    I'ROFKSSION 

and  own  an  incubator  to  be  absolutely  en  regie.  If  the  case 
goes  normally,  the  doctor  and  nurse  need  no  assistance. 
Cleanliness  is  the  rule  to  the  end.  1  f  operations  are  necessary, 
they  must  be  done  absolutely  under  antiseptic  ])recautions. 
In  cathetcrizaticju  especially,  be  careful  t(j  be  cleanly.  The 
nurse  may  use  one  good  vaginal  douche  of  corrosive  chloride 
of  mercury  one  to  five  thousand,  to  be  followed  at  once  by 
one  of  water  at  the  first  cleaning  up,  and  after  that,  if  any  are 
used,  use  only  sterilized  water.  Be  sure  the  syringe  is  asep- 
tic, or  you  do  more  harm  than  good.  I  prefer  acetanilide  or 
boric  acid  to  iodoform  for  use,  if  necessary,  on  both  mother 
and  child.  Solution  of  formaldehyde  will  probably  be  the 
antiseptic  most  used  in  these  cases  in  the  future.  During  my 
professional  career  I  have  delivered  a  great  many  w^omen,  and 
performed  about  all  of  the  obstetrical  operations,  from  Caesa- 
rean  section  down,  and  I  think,  in  fact  I  know,  I  can  more 
than  count  on  the  fingers  of  my  two  hands  all  of  the  septic 
cases  I  have  had.  Absolute  care  as  to  cleanliness  and  careful 
technique  has  been  my  rule. 

What  I  have  said  before  applies  to  cases  where  we  can 
elect  just  what  we  are  to  do,  and  do  it  secundum  arteni. 
What  about  the  other  cases? — the  cases  where  you  are  called 
just  on  the  eve  of  the  birth  of  the  child,  or,  may  be.  find  the 
child  born  on  your  arrival ;  the  woman  in  unclean  apart- 
ments, with  unclean  surroundings  of  every  kind,  including 
the  granny  and  officious  neighbors  just  run  in,  the  woman 
herself  unclean?  Well,  just  do  the  best  you  can.  Do  all  you 
can  to  clean  yourself  and  make  others  clean  around  you. 
There  is  a  proverb  that  '*  God  takes  care  of  little  children  and 
drunken  men."  We  may  add  to  this,  the  average  lying-in 
w^oman.  Do  as  you  may,  you  cannot  get  aseptic  conditions 
in  the  average  private  house,  in  the  average  private  lying-in 
patient,  in  the  average  attendants  on  these  cases.  All  you 
can  do  is  to  do  the  very  best  you  are  able,  and  trust  in  the 
Lord;  and  I  must  say  the  Lord  is  very  kind  to  these  poor 
sufferers.  One  thing  favors  patients  in  general  obstetrical 
practice,  especially  when  away  from  the  medical  centres :  the 

105 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

normal  ^'agi^a  will  take  care  of  a  few  of  the  average  germs, 
whether  pathogenic  or  benign,  and  physicians  away  from 
centres  are  much  less  liable  to  carry  contagion  than  those 
constantly  exposed  in  the  crowded  districts.  Always  remem- 
ber one  thing:  if  exposed  to  a  septic  case,  especially  if  you 
have  handled  a  case,  particularly  an  abdominal  or  a  pelvic 
case,  where  sepsis  has  been  well  established,  wash  as  you 
may,  use  germicides  as  you  may,  you  cannot  make  your  hands 
aseptic  in  less  than  forty-eight  hours,  and  you  run  the  risk 
of  taking  the  life  of  any  surgical  or  obstetrical  case  you  ap- 
proach within  that  time.  Under  aseptic  methods  the  public 
hospital  is  now  just  as  good  and  desirable  for  surgical  cases 
as  the  same  hospital  was  undesirable  and  unfit  twenty-five 
years  ago.  To-day  the  public  lying-in  hospital,  instead  of 
being  a  charnel-house,  is  above  all  other  places  the  safest  and 
most  desirable  place  for  the  confinement  and  treatment  of  par- 
turient women.  Indeed,  it  is  the  only  possible  way  to  give 
them  aseptic  accouchement  with  absolute  aseptic  surround- 
ings and  conditions.  In  my  judgment  it  would  be  well  now 
if  every  community  had  its  lying-in  resort,  to  which  any 
woman  could  fiee  as  a  safe  refuge  in  her  great  trials.  I  have 
little  doubt  that  the  coming  woman  will  have  such  refuge  and 
generally  avail  herself  of  it,  with  men  and  women  as  special- 
ists in  obstetrics,  which  will  insure  more  perfect  aseptic  condi- 
tions than  the  general  practitioner  can  give. 

In  abortion  or  miscarriage,  any  time  before  the  viability  of 
the  foetus,  antiseptic  precautions  are  of  great  importance,  and 
I  think  much  of  the  blame  given  to  the  use  of  the  intra- 
uterine curette  is  because  we  are  not  sufficiently  careful  of 
antisepsis  in  its  use.  If  you  find  you  cannot  check  the  prema- 
ture expulsion  of  the  ovum,  say  before  the  fourth  month,  do 
not  hesitate  to  use  an  antiseptic  tampon,  made  of  any  material, 
— iodoform  gauze,  bichloride  gauze,  or  of  house  rags  even, — 
soaked  with  bichloride  one  to  four  thousand.  Often  we  have 
to  take  the  best  material  we  can  find.  Use  a  boric  acid  douche, 
and  pack  in  the  tampon  well ;  give  ergot  and  quinine,  and  in 
from  twenty-four  to  thirty-six  hours  you  should  find  the 

io6 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

ovum  unruptured  in  the  vagina,  with  no  necessity  of  entering 
the  uterus  either  with  the  finger  or  instrument.  Give  a  hot 
vaginal  boric  acid  douche  if  you  choose,  also  intra-uterine,  at 
once,  and  nature  and  good  care  will  do  the  rest.  It  is  the 
ruptured  ovum  that  gives  the  tnnihlc.  This  must  be  gotten 
rid  of  promptly,  if  possible,  especially  if  there  be  the  least 
odor,  and  here  the  curette  comes  in.  The  patient  should  be 
thoroughly  washed  externally,  and  physician  and  nurse 
should  also  thoroughly  wash  up  antiseptically.  .Use  the  hol- 
low curette  invented  by  the  great  Vienna  obstetrician,  Carl 
Braun;  they  come  in  sets  of  three, — one  spoon,  one  sharp, 
and  one  dull,  with  a  common  handle  to  screw  on.  Attach 
your  curette  to  a  fountain  syringe  containing  your  fluid,  and 
then  you  can  irrigate  as  you  curette.  Curette  a  uterus  with- 
out these  precautions,  and  you  run  great  risk  of  infecting 
your  patients.  Be  rough,  tear  the  lining  membrane  of  the 
uterus,  and  thus  infection  may  enter.  Be  rough,  and  you 
even  may  go  through  the  organ. 

There  is  another  trouble  which  will  bear  watching, — viz., 
laceration  of  the  cervix  during  labor,  either  by  the  foetus,  by 
instruments,  or  by  the  hand  of  the  obstetrician.  Here  we 
may  have  free  and  even  fatal  hemorrhage.  Of  course,  the 
surgical  way  is  to  draw  out  the  uterus,  which,  with  the  proper 
instruments,  can  easily  be  done  in  its  relaxed  condition,  and 
suture  and  tie  the  vessel  or  vessels  if  necessary,  which  will 
not  often  be  necessary.  When  in  a  position  where  you  cannot 
do  this,  and  this  often  may  happen,  pack  the  laceration  with 
lint  or  absorbent  cotton,  or  any  porous  material,  soaked  in 
liquid  subsulphate  of  iron,  and  the  case  must  be  a  very  serious 
one,  indeed,  if  the  hemorrhage  does  not  stop  at  once.  The 
iron  itself  is  an  antiseptic,  and  a  good  one.  Injections  of  hot 
water  may  be  tried,  and  will  often  be  found  to  succeed.  Bear 
in  mind  this  injunction:  whenever  you  have  hemorrhage 
from  the  genital  tract  in  a  woman,  watch  it.  Alwa}'s  find  out 
the  cause  and  the  point  where  from.  There  are  many  causes, 
as  we  all  know,  of  such  hemorrhage.  If  it  happen  to  be  of 
malignant   origin,    delay   is    fatal.      Glandular    involvement 

10- 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

comes  on,  and  your  patient  is  lost.  An  early  diagnosis  gives 
the  surgeon  his  opportunity  and  the  patient  her  one  and  only 
chance.    This  \ve  are  learning  every  day. 

In  malignant  disease,  where  possible,  operate  early,  operate 
radically,  avoid  hemorrhage,  and  hence  avoid  shock.  On  this 
line  S.  W.  Gross  and  Halsted  have  been  pioneers  among  us. 
This  rule  applies  to  the  little  crack  on  the  lip  which  does  not 
heal.  Do  not  let  the  glands  near  it  enlarge  before  you  get 
rid  of  it.  This  rule  applies  to  rodent  ulcer  and  to  lympho-  or 
other  sarcomas.  Then  do  not  wait  for  them  to  spread  by  the 
blood-vessels  before  you  get  rid  of  them. 

Genito-urinary  surgery,  like  general  surgery,  has  greatly 
benefited  by  modern  methods  and  modern  ideas.  First,  as 
to  gonorrhoea  in  the  male.  Forty  years  ago  we  knew  little 
or  nothing  of  its  pathology.  Now  we  know  it  is  caused  by  a 
specific  micro-organism,  the  gonococcus  of  Neisser.  I  wish 
I  could  say  as  much  for  the  treatment.  Forty  years  ago  we 
thought  ourselves  fortunate  if  our  patients  were  free  in  six 
weeks ;  to-day  we  are  satisfied  if  we  can  dismiss  them  well  in 
about  the  same  time.  It  might  be  supposed,  knowing  the 
cause,  and  that  cause  a  microbe  confined  to  a  small  and  easily 
approachable  space,  all  we  had  to  do  would  be  to  apply  a  ger- 
micide and  that  would  end  it.  Not  so.  It  is  a  question 
whether  germicides  are  ever  efficient  applied  to  microbes  on 
mucous  membrane;  whether  to  be  successful  they  must  not 
reach  beyond.  There  are  some  new  silver  salts  coming  up 
now  for  which  great  claims  are  made,  but  upon  what  scien- 
tific grounds  I  do  not  as  yet  know.  In  my  experience  the 
average  case  of  gonorrhoea  does  just  as  well,  and  very  many 
of  them  much  better,  especially  as  to  unfortunate  sequelae, 
when  treated  by  rest,  at  least  as  much  as  we  can  get  the  pa- 
tient to  take,  a  very  restricted  diet,  as  near  to  sterilized  milk 
as  we  can  get,  urethral  irrigations  of  sterilized  water,  with 
absolute  general  cleanliness,  the  wearing  of  a  suspensory 
truss  and  a  protecting  bag  for  the  penis,  with  a  little  absorbent 
cotton  in  the  end,  dampened  with  a  little  of  a  one  or  two  per 
cent,  formaldehyde  solution. 

io8 


FORTY    YEARS    IN   THE   MEDICAL    PROFESSION 

Until  we  can  assure  ourselves  of  a  successful  application 
to  destroy  the  micro-organisms,  I  am  almost  sure  the  fore- 
going is  the  safest  and  best  treatment  for  the  average  case  of 
gonorrhcea  in  the  male.  Always  be  sure  to  warn  your  patient 
of  the  danger  of  infecting  his  own  or  other  persons'  eyes  by 
reckless  use  of  hands,  towels,  etc.,  and  in  treating  gleets  al- 
ways combine  dilatation  of  the  urethra  with  your  treatment. 
As  to  the  silver  salts,  I  would  prefer  protargol.  For  simple 
clap,  first  stage,  with  the  gonococci  present,  inject  three  to  five 
times  in  twenty-four  hours,  preferably  warm,  a  penis  syringe- 
ful  of  one  per  cent,  solution,  holding  it  several  minutes.  This, 
like  all  injections,  at  first  causes  smarting  and  increases  the 
discharge.  After  four  days  the  gonococci  should  diminish 
and  also  the  discharge;  then  use  the  injection  twice  only  in 
twenty-four  hours,  and  when  gonococci  have  disappeared  use 
simple  astringent  injections.  If  this  happy  result  is  main- 
tained in  a  number  of  cases,  in  more  than  my  experience  yet 
justifies,  it  would  go  to  place  protargol  as  a  germicide  to  the 
gonococcus.  For  posterior  urethritis,  irrigate  with  a  quarter 
of  one  per  cent,  solution  of  protargol,  preceding  it  by  a  boric 
acid  irrigation,  with  salol  by  the  mouth.  For  the  deep  ure- 
thritis which  causes  so  much  sufifering,  apply  locally  a  few 
drops  of  nitrate  of  silver  solution,  one  to  one  thousand. 

In  the  female  about  the  same  rules  will  apply.  AVe  know 
now  that  here  the  urethra  is  most  often  involved,  and  that  the 
walls  of  the  vagina  are  sometimes,  but  not  at  all  in  very  many 
cases.  The  best  treatment  is  by  irrigations  of  urethra  and 
vagina  and  uterus  when  possible,  distending  the  vagina  to  its 
utmost  limit  so  the  fluid  may  come  in  contact  with  all  parts, 
and  by  the  use  of  suppositories  of  cocoa-butter,  etc.  There 
is  one  serious  trouble  following  gonorrhoea  in  the  female 
which  has  come  to  the  front  in  the  evolution  of  bacteriology 
and  gynaecology, — viz.,  gonorrhoeal  salpingitis,  which  may 
be  acute  or  chronic:  so  always  look  out  for  it.  for  many  a 
poor  virtuous  woman  suflfers  from  it.  as  a  result  of  connubial 
infection,  for  no  one  knows  the  limit  of  life  of  the  gonococcus 
of  Neisser,  and  man  may  carry  it  as  long  as  he  has  the  least 

109 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

remnant  of  a  gieety  discharge.  As  a  rule,  I  think  its  life 
limited,  and  colonies  like  the  colonies  of  micro-organisms 
generally,  generate  their  own  poison  and  die.  Toxines  de- 
veloped in  the  urine  of  the  individual  may  destroy  them  and 
be  one  way  of  cure,  but  from  the  nature  of  the  case,  these 
gleet  cases  are  exceptions,  and  these  exceptipns  are  the  sad 
cases. 

In  epididymitis,  orchitis,  and  other  sequelae  of  gonorrhoea 
there  has  been  little  change  to  note  in  the  treatment.  You 
may  still  take  your  choice,  from  strapping,  puncture,  suspen- 
sion, rest,  and  a  diet  as  near  sterilized  milk  as  possible.  In 
the  treatment  of  strictures  of  the  male  urethra  antiseptic  sur- 
gery has  helped  much,  as  septic  troubles  now  must  rarely  fol- 
low treatment  of  such  by  operation.  Thirty  years  ago  the 
treatment  by  divulsion  was  common,  and  Holt's  instrument 
was  in  the  hands  of  most  genito-urinary  surgeons.  This 
method  has  deservedly  fallen  into  disuse,  and  dilatation,  in- 
ternal urethrotomy,  external  urethrotomy  with  and  without  a 
guide,  and  resection  of  the  stricture  and  suture  of  the  urethra 
are  now  most  in  vogue. 

Operations  for  exstrophy  of  the  bladder  now  have  a  better 
chance  since  the  introduction  of  antisepsis,  but  at  best  are  not, 
as  a  rule,  satisfactory.  Surgeons  do  not  hesitate  to  attack 
any  part  now,  and  great  advances  have  been  made  in  the 
treatment  of  all  bladder  troubles,  and  particularly  of  troubles 
involving  the  prostate,  and  by  the  able  work  of  White  and 
others  castration  and  division  of  the  vas  deferens,  and 
even  more  radical  operations  on  the  prostate  itself,  promise 
some  relief  to  sufferers  from  such  afflictions.  The  relief  for 
stone  in  the  bladder  has  somewhat  changed.  Thirty  years 
ago,  the  lateral  operation  was  almost  universally  used,  the 
bilateral  rarely,  the  median  operation  being  sometimes  used 
for  small  stones.  Then,  greatly  through  the  work  of  Sir 
Henry  Thompson  and  Civiale,  lithotrity  became  much  used; 
and  after  this,  by  aid  of  Dr.  Bigelow,  of  Boston,  litholapaxy, 
or  removing  the  stone  by  aspiration  after  crushing,  became 
most  frequently  used.     Now  the  old  operation  of  suprapubic 

no 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

lithotomy  has  been  revived,  and  is  often  and  very  successfully 
done.  Much  credit  is  due  to  Dr.  Charles  Winslow  Dulles,  of 
Philadelphia,  for  work  done  in  reviving  this  very  easy  and 
rational  way  of  relieving  so  serious  a  trouble.  The  chief 
danger  to  be  feared  after  this  operation  is  a  fistulous  opening, 
which  may  decline  to  heal,  and  thus  give  great  trouble. 

In  syphilis  there  have  been  many  changes  during  forty 
years,  but  whether  it  is  of  microbic  origin  or  ncjt  is  not  yet 
known.  We  no  longer  hear  of  unicists  and  dualists.  We 
know  now  that  chancre  is  the  initial  lesion  of  syphilis,  and 
that  the  chancroid  or  soft  chancre  is  not  a  syphilitic  lesion, 
and  is  never  followed  by  syphilitic  infection.  We  know  Ricord 
was  right  when  he  said  chancre  was  not  auto-inoculable  as 
chancre,  and  that  chancroid  is  auto-inoculable.  We  know 
that  bubo  following  chancre  is  hard,  and  that  following  chan- 
croid often  suppurates.  We  know  now  that  we  may  have  a 
mixed  initial  lesion,  being  a  chancre  and  chancroid  coming 
on  the  same  spot.  I  am  uncertain  about  this,  but  it  may  let 
many  a  man  out  on  diagnosis,  at  any  rate;  and  when  doubt- 
ful, treat  it  as  a  chancre  anyhow.  Forty  years  ago  ever}- 
effort  was  made  to  eradicate  the  chancre  as  soon  as  it  ap- 
peared, strong  caustics  being  used;  and  excision  was  prac- 
tised at  Blockley,  and  is  even  now  in  vogue.  It  was  formerly 
thought  this  getting  rid  of  the  initial  lesion  might  abort  the 
disease,  but  I  do  not  think  this  idea  holds  now,  and  the  local 
treatment  is  chiefly  antiseptic.  Do  not  order  iodoform  for 
your  patient,  or  you  convict  him  at  once  wherever  he  goes 
among  men  about  town,  and  no  man  reeking  with  the  stink  of 
iodoform  is  fit  to  associate  with  his  fellow-man.  Chancroids 
are  not  now,  as  a  rule,  cauterized,  but  treated  with  antiseptic 
dressings,  as  carbolic  acid,  corrosive  sublimate,  solution  of 
formaldehyde,  or  the  old  black  wash.  For  bubo  after  chancre, 
constitutional  treatment,  and  for  bubo  after  chancroid,  treat 
antiseptically,  and  by  injecting  carbolic  acid  and  such  reme- 
dies and  dissecting  out  parts  of  glands  not  broken  down  by 
suppuration.  In  the  treatment  of  secondar}-  symptoms  we 
still  rely  on  mercury  and  the  iodides,  as  of  old.     Inunctions 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

and  ftimigations  are  still  used.  The  newer  form  of  treatment 
is  by  hypodermic  medication,  and,  if  your  patient  will  submit 
to  it,  is  useful,  if  your  case  is  pressing.  When  you  give 
iodide  of  potassium  alone,  give  it  in  milk ;  it  adds  greatly  to 
its  tonic  and,  I  think,  to  its  specific  effect.  If  iodide  of  potas- 
sium does  not  agree,  give  iodide  of  sodium;  it  is  just  as 
effectual.  Now  and  again  you  will  find  a  case  unable  to  touch 
iodine  in  any  form.  This  is  unfortunate  for  the  patient. 
Coryzas,  skin  eruptions,  and  other  troubles  make  his  life 
miserable  whilst  taking  iodine.  Mercury  and  some  of  the 
antisyphilitic  vegetable  remedies  are  your  only  resource. 

Decided  advance  has  been  made  in  the  treatment  of  the 
tertiary  stages,  especially  in  syphilis  of  the  nervous  system, 
and  wonderful  results  are  obtained  by  heroic  doses  of  the  spe- 
cific remedies.  One  thing  we  know  in  regard  to  the  acquire- 
ment of  syphilis :  it  is  often  acquired  by  virtuous  people  inno- 
cently. The  secondary  as  well  as  the  primary  lesions  are 
contagious,  and  the  only  wonder  is  that  it  is  not  spread  much 
more  generally  than  it  is.  A  knowledge  of  this  fact  should 
make  us  impress  on  all  the  absolute  necessity  of  great  care  in 
using  public  drinking-cups,  of  the  danger  of  promiscuous  kiss- 
ing, and  all  such  useless  modes  of  greeting  mere  acquaint- 
ances ;  in  fact,  let  it  be  generally  known  that  the  most  loath- 
some of  diseases  lurks  wherever  human  beings  congregate. 
When  your  boy  is  growing  up,  teach  him  to  confide  in  you, 
and  if  ever  troubles  of  this  kind  cause  him  suspicion,  have  a 
course  laid  out  for  him  to  pursue,  either  to  come  to  you  or  go 
to  his  physician,  and  thus  avoid  what  probably  may  be  to  him 
absolute  ruin,  for  this  comes  to  many  a  good  boy,  who  is  un- 
fortunate in  this  respect,  and  most  are  victims  to  the  cupidity 
and  ignorance  of  quacks  or  the  ever-ready  drug-store  clerk. 
I  have  practised  medicine  too  long  not  to  have  met  scores  of 
sad  cases.  The  best  advice  I  can  give  to  the  young  man  is 
contained  in  two  short  lines : 

"  Pollute  not  with  a  harlot's  cheek 
Those  lips  made  sacred  by  a  mother's  kiss." 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

In  the  siirg'cry  of  the  eye  j^rcat  advances  liave  been  niarle 
since  1  entered  the  pn^fession,  and  date  from  about  the  time 
when  Von  Graefe  gave  to  the  profession  his  classic  on  "  Glau- 
coma: Its  Nature  and  Treatment."  As  to  glaucoma,  I  have 
seen  in  consultation  a  number  of  cases,  especially  of  acute 
glaucoma,  where  a  failure  to  recognize  the  condition  early 
caused  lamentable  trouble  and  loss  of  vision.  Careless  or 
ignorant  practitioners  are  very  liable  to  slip  up  on  glaucoma, 
and  we  cannot  be  too  careful  to  have  our  wits  about  us  when 
such  game  is  around.  Another  point  here  :  where  glaucoma 
is  suspected,  or  your  patient  is  over  forty  years  old,  be  careful 
of  the  use  of  atropine  as  a  mydriatic.  There  is  an  apparent 
contradiction  here,  too,  among  experts,  for  atropine  is  said  by 
some  to  lessen  tension  of  the  eyeball,  and  this  is  what  we 
need  in  glaucoma.  Horatio  Wood  says  be  careful  of  it,  be- 
cause the  dilatation  of  the  pupil  causes  the  iris  to  press  against 
the  spaces  of  Fontana,  and  that  it  may  impede  or  stop  the 
lymph  circulation  in  these  spaces,  which  have  been  already 
narrowed  by  disease.  Hydrobromate  of  homatropine  and  co- 
caine are  better  and  safer  mydriatics  for  general  use,  as  their 
effects  pass  off  in  a  iew  hours,  while  the  effect  of  a  thorough 
application  of  atropine  sulphate  lasts  a  number  of  days.  Eser- 
ine  has  the  opposite  effect  of  atropine,  and  has  been  a  great 
help  to  the  ophthalmic  surgeon  since  its  introduction.  This 
is  such  an  important  matter,  and  so  much  harm  may  be  done 
by  general  practitioners  in  the  use  of  atropine,  that  I  think 
the  following  rules  are  worthy  of  study  by  all :  ( i )  Use  it 
in  iritis  at  any  age,  old  or  young,  but  in  young  children  be- 
ware of  too  strong  solutions,  or  constitutional  symptoms  of 
poison  may  arise.  (2)  Use  it  in  ulcer  of  cornea  and  in  kera- 
titis. (3)  In  refractive  work  in  patients  under  forty  use  it. 
but  homatropine  is  better ;  also  use  it  as  a  mydriatic  in  persons 
under  forty,  but  cocaine  and  homatropine  are  probably  better. 
(4)  Do  not  use  atropine  in  conjunctivitis.  (5)  Never  use 
it  in  glaucoma. 

Antisepsis  has  also  done  as  much  to  help  the  oculist  in  his 
results  as  it  has  done  in  general  surgery,  and  it  is  wonderful 
8  113 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

what  the  eye  endures  in  such  appHcations.  but  the  results  jus- 
tify the  means  used  over  and  over.  Local  anaesthesia,  since  its 
comparatively  recent  introduction,  has  been  the  great  boon 
to  both  patient  and  surgeon  in  eye  cases.  Cocaine  is  chief 
among  these,  and  it  is  wonderful  to  see  the  effect  of  the  dis- 
tillation of  a  few  drops  of  a  four  per  cent,  solution  into  an 
eye.  In  most  operations  it  has  taken  the  place  of  general 
anaesthesia,  and  reduced  pain  and  unfavorable  results  to  a 
minimum.  Speaking  of  local  anaesthesia,  it  has  done  just  as 
much  for  general  surgery.  Cocaine  is  the  base  of  most  of  it, 
but  not  all.  Freezing  mixtures  which  work  by  rapid  evapo- 
ration, like  ethyl  chloride,  rhigolene,  and  such,  are  very  useful 
in  minor  operations.  Schleich's  method,  by  cocaine  and  mor- 
phia and  local  distention  by  the  subcutaneous  injection  com- 
bined, is  effectual,  but  has  not  yet  generally  commended  itself 
as  practical.  The  late  Professor  Theophilus  Parvin  was  a 
strong  advocate  of  this  plan.  Cocaine  is  not  a  remedy  to 
trifle  with;  it  may  cause  serious  trouble  from  subcutaneous 
use,  and  one  may  soon  become  a  cocaine  fiend  from  frequent 
application  of  a  solution  or  powder  to  mucous  membrane. 
Beware  how  you  recommend  it  in  hay  fever  and  such  trou- 
bles! 

To  return  to  the  eye.  Great  advances  have  been  made  in 
treating  errors  of  refraction  and  such  troubles  by  glasses, 
and  many  are  now  made  comfortable,  where  formerly  their 
inconvenience  was  ever  present,  and  many  a  luckless  school- 
boy or  girl,  who  thirty  years  ago  would  have  been  hustled 
into  a  corner  as  a  dullard,  has  now  become  the  bright  scholar 
of  the  school-room  and  the  fond  hope  of  parents. 

Ear  surgery  has  made  wonderful  advances,  and  under  the 
leadership  of  C.  H.  Burnett,  of  Philadelphia,  followed  by 
Randall  and  others,  great  relief  has  been  afforded  to  sufferers. 
Equally  good  work  has  been  done  in  throat  work,  and  all 
such  work  has  been  taken  from  the  domain  of  general  surgery 
and  become  special  work. 

During  the  last  forty  years  we  have  seen  a  new  branch  of 
surgery  entirely,  and  since  the  introduction  of  antisepsis  we 


FORTY    YEARS    IN    THE   MEDICAL   PROFESSION 

have  seen  the  most  wonderful  results.  Operations  have  been 
clone  never  even  dreamed  of  before,  and  thousands  of  lives 
saved  which  before  this  advent  would  have  been  doomed  to 
cruel  suffering  and  premature  death,  i  refer  to  gynaecology. 
J.  Marion  Sims  was  the  great  pioneer  and  master  here,  and 
his  great  work  was  done  for  the  cure  of  vesico- vaginal  fistula. 
Dr.  T.  A.  Emmett  has  also  been  a  shining  light  in  this  branch 
of  surgery,  and  first  performed  vaginal  cystotomy  for  the 
relief  and  cure  of  cystitis  in  the  female.  McDowell  made  his 
first  ovariotomy  in  1809,  and  no  great  advance  was  made 
beyond  this  until  within  the  last  fifty  years.  Since  then  the 
whole  system  of  gynaecology  has  been  really  built  up,  and  now 
nothing  is  too  hidden  or  intricate  to  be  delved  after,  and  an 
exploratory  incision  through  the  abdominal  walls  is  thought 
no  more  of  than  would  have  been  the  amputation  of  a  finger 
when  McDowell  commenced  the  great  w^ork.  Gynaecology 
is  among  the  most  alluring  of  all  the  specialties  in  medicine, 
and  where  a  few  years  ago  there  were  only  a  few  here  and 
there  in  the  denser  centres  of  population,  to-day  they  number 
many  in  the  surgical  corps  of  every  city  in  the  world,  and  the 
merest  tyros  in  the  business  perform  operations  which  a  short 
time  ago  would  have  confounded  a  McDowell  or  a  Sims.  Ob- 
stetrics and  gynaecology  are  now  combined,  and  the  obstetri- 
cian is  necessarily  a  surgeon;  very  different  from  what  it 
was  when  I  w^as  a  student  at  the  University.  Then  the  pro- 
fessor of  obstetrics  rarely  touched  a  knife,  and,  indeed,  the 
professional  etiquette  of  the  day  compelled  him  rather  to  seek 
the  surgeon  in  surgical  cases,  as  Charles  D.  Meigs  sought 
William  Gibson  in  his  celebrated  Csesarean  section  case,  the 
case  where  Meigs  delivered  the  woman  twice  after  craniot- 
omy, and  Gibson  delivered  her  twace  by  the  Cassarean  sec- 
tion. Although  no  anaesthetic  was  used,  the  woman  declared 
the  knife  made  the  easiest  delivery.  Such  operations  have 
since  been  much  changed  and  modified,  and  the  child,  uterus, 
and  appendages  are  all  frequently  removed  at  one  time,  as 
was  first  done  by  Porro.  I  made  the  eleventh  Porro  Caesa- 
rean  section  in  this  country,  in  the  case  of  a  rachitic  dwarf 

115 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

with  a  collapsed  pelvis,  complicated  with  uterine  fibroids. 
The  child  weighed  eight  pounds,  and  the  uterus,  tumors,  and 
appendages  weighed  eight  pounds.  The  woman  died  several 
days  after  from  exhaustion,  but  the  boy  is  now  a  sturdy 
youth,  large  and  well  developed  in  every  way. 

General  surgery  now  attacks  the  abdomen  in  various  ways, 
and,  wonderful,  indeed,  what  appears  to  be  almost  super- 
natural work  is  done  daily;  in  fact,  none  of  the  cavities  are 
exempt  from  the  surgeon's  hand ;  the  skull,  the  chest,  and  the 
abdomen  are  all  within  his  circle.  Brain  surgery  has  as  yet 
not  produced  the  most  encouraging  results,  and  operations 
for  epilepsy  and  such  affections  are  unfortunately  as  yet  far 
from  encouraging.  In  traumatic  conditions  wonders  are  ac- 
complished. In  the  chest  also  great  and  successful  work  is 
done  daily,  and  anything  may  be  expected  as  occasion  arises. 
In  the  abdomen  the  surgery  of  the  kidney,  and  even  of  the 
liver,  is  daily  expanding,  and  great  relief  is  now  afforded  in 
cases  only  recently  given  over  to  hopelessness  and  despair. 
Intestinal  surgery  shows  the  most  remarkable  results :  wounds 
are  closed,  long  lengths  of  the  intestines  are  removed  and  the 
ends  joined  by  various  methods,  as  by  Murphy's  buttons  and 
such  like,  and  recovery  of  organ  and  function  follows  as  a 
matter  of  course.  Indeed,  only  recently  the  stomach  has  been 
removed,  the  ends  of  the  intestine  and  oesophagus  joined,  and 
the  patient  recovered  and  enjoyed  her  food,  thrived  and  did 
well,  thus  upsetting  all  theories  of  physicians,  surgeons,  and 
especially  of  the  physiologists. 

Speaking  of  Murphy's  buttons,  some  time  since  a  success- 
ful operator  took  one  from  his  vest  pocket,  remarking  that  it 
had  been  through  patients  fourteen  different  times,  and  I 
think  in  one  of  its  journeys  consumed  forty  days  in  its  wan- 
derings before  passing  out.  What  will  not  happen!  When 
Proctor  Knott  made  his  celebrated  speech  in  Congress,  poking 
fun  and  ridicule  on  the  young  city  of  Duluth,  it  was  consid- 
ered a  great  hit  and  worthy  of  a  great  humorist.  To-day 
Duluth  has  grown  to  be  a  great  town,  and  more  than  justifies 
in  its  reality  and  greatness  all  that  Knott  said  of  it  in  fun  and 

ii6 


FORTY    YEARS   IN   THE   MEDICAL   PROFESSION 

satire,  and  more,  much  more.  So  it  is  in  incdiciiie;  it  is  a 
progressive  science  truly,  and  in  the  futine  nothing  that  may 
happen  can  surprise  or  emharrass  us.  liven  the  exaggeration 
of  the  old  countryman's  story,  told  in  the  wayside  inns  of 
many  years  ago,  may  not  startle  us.  lie  iiad  some  bowel 
trouble,  and  sent  for  the  doctor.  The  doctor  arrived,  made 
his  diagnosis,  and  without  further  formality  sent  for  a  sheep, 
cut  open  the  man  and  also  the  sheep,  cut  ofT  many  feet  of  the 
man's  bowel,  did  the  same  to  the  sheep,  attached  the  sheep's 
to  the  man's,  sewed  him  up  and  left,  remarking  that  the  sheep 
would  make  good  mutton.  The  doctor  some  time  after,  meet- 
ing his  patient,  asked  him  how  he  felt.  "  Oh,  first  rate,  doc- 
tor, except  the  beastly  hankering  I  have  after  grass." 

Appendicitis  is  the  trouble  that  has  excited  the  most  in- 
terest among  both  physicians  and  laymen  in  recent  years. 
Of  course,  it  has  always  existed  and  has  always  been  treated, 
and  in  many  cases  recovered  through  medical  treatment  alone, 
as  they  do  now,  and  doubtless  many  cases  died  that  would 
now  be  saved  by  operation.  There  are,  of  course  a  number 
of  troubles  in  the  region  of  the  right  iliac  fossa  which  do  not 
involve  the  appendix,  but  if  inflammation  goes  on,  every- 
thing in  the  end  becomes  in^^olved.  Many  cases  that  for- 
merly passed  as  obstruction  of  the  bowels,  and  died  as  such, 
probably  involved  the  appendix  and  its  surroundings.  Is  the 
condition  generally  spoken  of  as  appendicitis  more  common 
than  formerly?  Personally  I  have  little  doubt  but  that  it  is. 
The  causes  may  be  various.  It  appears  to  be  rather  common 
in  young,  vigorous  men,  those  who  are  given  to  athletics, 
cycling,  and  such  exercise,  especially  suffering,  it  appears  to 
me,  although  I  have  no  statistics  on  the  subject.  Rheumatism 
and  gout  are  thought  to  contribute  to  the  cause  of  true  in- 
flammation of  the  appendix.  What  effect  toxines  may  have 
in  producing  it,  toxines  introduced  by  the  food  or  developing 
from  the  food  are  to  be  taken  into  account,  I  think,  aj-  a  cause, 
for  the  reason  that  we  are  consuming  food,  cold-storage  food, 
canned  food,  and  preserved  foods  of  all  kinds  in  large  quanti- 
ties, all  of  Avhich  might  be  in  shape  to  produce  more  or  less  of 

11/ 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

toxine  troubles  as  affecting  the  digestive  tract,  far  beyond  the 
possibiHty  of  such  action  which  the  sound  fresh  foods  of  for- 
mer years  could  possibly  have  produced.  Probably  the  most 
frequent  cause  of  appendicitis  is  the  bacillus  coli  communis, 
and  these  very  sources  of  food  we  have  been  speaking  of,  I 
think,  are  surely  one  of  the  great  causes  of  the  increase  of 
such  micro-organisms  in  the  bowels  of  human  beings. 

Inflammation  of  the  gall-bladder  is  another  disease  on  the 
increase,  and  is  also  doubtless  most  frequently  caused  by  this 
same  bacillus  coli  communis.  Thus  we  see  how  our  knowl- 
edge of  the  cause  of  disease  advances  just  in  proportion  as 
our  knowledge  of  pathogenic  germs  grows.  Appendicitis 
and  cholecystitis  are  probably  the  most  frequent  causes  of 
peritonitis,  and  both  are  now  cured  by  the  surgeon.  This 
colon  bacillus  may  often  cause  embarrassment  in  diagnosis 
of  troubles  within  the  peritoneal  cavity.  A  healthy  man  may 
bolt  a  lot  of  under-done  beef.  The  digestive  juices  are  nat- 
urally antiseptic,  and  this  undigested  mass  passes  to  the  colon. 
What  a  lovely  host  for  the  bacillus !  They  are  soon  evolved 
by  the  million,  a  subacute  colitis  is  set  up,  which  may  or  may 
not  run  on  and  involve  the  appendix  and  its  surroundings,  or 
the  bacilli  may  pass  up  and  involve  the  gall-bladder ;  even  a 
rigor  and  fever  may  follow  from  toxaemia  set  up,  and  yet  in 
the  end  there  may  be  no  pus,  but  the  patient  will  be  lucky  to 
escape  pus  formation  with  all  which  that  implies.  The  ner- 
vous system  will  play  a  part;  an  urticaria  may  be  set  up; 
urticaria  is  doubtless  a  vasomotor  neurosis,  and  ptomaine 
poisoning  to  a  greater  or  less  degree  will  be  responsible  for 
these  symptoms.  There  may  be  other  factors,  but  I  look  on 
these  I  have  mentioned  as  some,  at  least,  of  the  causes  ren- 
dering appendicitis,  a  grave  trouble,  of  more  frequent  occur- 
rence than  formerly. 

Since  the  developing  of  antisepsis  there  has  been  a  revival 
of  operations  for  the  radical  cure  of  hernia.  I  remember 
assisting  Dr.  Agnew  in  a  number  of  his  operations  by  his 
method,  and  one  or  two  did  well  for  quite  a  long  time;  but 
I  never  thought  he  greatly  favored  the  procedure  as  a  very 

ii8 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

satisfactory  one  as  to  results.  S.  I).  Gross  never  had  any 
faith  in  the  radical  cure;  that  is  to  say,  he  gave  it  little  atten- 
tion as  a  practical  measure  so  far  as  my  experience  with  him 
went.  I  have  seen  the  result  of  some  good  work  recently 
done  by  Dr.  T.  S.  K.  Morton,  and  so  far  it  is  good  and  very 
promising  as  to  later  results.  Halsted,  of  Johns  Hopkins, 
and  Fowler,  of  the  New  York  Polyclinic,  have  also  lately 
done  some  good  work  by  modifications  of  Bassini's  operation, 
the  anterior  displacement  of  the  cord.  Fowler's  modification 
is  somewhat  complicated,  but  seems  to  greatly  strengthen  the 
original  procedure  of  Bassini.  Injections  of  irritants  into  the 
tissues  about  the  rings  have  been  advocated  and  practised,  but 
not  with  sufficient  success  in  my  experience  to  recommend  it, 
yet  I  am  fully  persuaded  that  sufficient  progress  has  been 
made  in  this  direction  to  cause  surgeons  to  give  it  very  care- 
ful attention  and  study.  Time  alone  can  show  the  results  in 
such  work,  and  I  trust,  for  the  sake  of  suffering  humanity, — 
one  in  five  suffering  from  hernia  in  some  form, — general 
relief  may  come  in  good  time  to  all  by  operation. 

Tracheotomy  has  seen  quite  a  revival  during  recent  years, 
and  by  the  work  of  Wharton,  of  Philadelphia,  and  others  the 
mortality  has  been  reduced  in  these  terrible  cases  of  laryngeal 
stenosis.  Intubation,  introduced  and  made  an  every-day  prac- 
tical procedure  by  O'Dwyer,  has  taken  the  place  in  a  great 
measure  of  tracheotomy,  especially  in  children.  The  trouble 
in  tracheotomy  in  these  cases  is  to  get  parents  to  consent  to 
the  operation  before  it  is  too  late.  Intubation  comes  in  most 
opportunely  in  just  such  cases,  for  almost  any  parent  is  willing 
to  allow  the  use  of  the  tubes,  and  they  doubtless  are  destined 
to  save  much  agonizing  suffering  and  many  lives.  Besides 
the  many  operations  on  the  eyes  and  ears,  and  the  general 
operations  of  the  gynaecologist,  which  are  comparatively  re- 
cent, I  may  mention  excision  of  the  lower  end  of  the  rectum 
for  malignant  disease.  This  extensive  operation  is  now-  fre- 
quently done,  and  W.  W.  Keen  has  been  very  successful  in  a 
number  of  cases.  It  is  wonderful  how'  long  those  who  recover 
from  the  operation  live  before  a  return  of  the  original  trouble. 

IIQ 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

I  kno\y  of  one  case  of  Ransley's  in  good  health  after  more 
than  six  years.  Of  course,  before  the  rectum  operation  a 
colostomy  is  done. 

Many  operations  on  the  brain  are  now  done  and  are  com- 
paratively new,  but,  as  before  mentioned,  cases  other  than 
traumatic  ones  are  not  encouraging.  Wyeth's  method  of 
amputating  at  the  hip  is  comparatively  new,  and  an  improve- 
ment on  old  methods;  and  so  is  Gant's  operation  for  defor- 
mity after  hip-disease.  Electrolysis  for  aneurism,  with  the 
addition  of  Stewart's  method  by  wire,  promises  some  good 
results  in  these  desperate  cases,  as  does  Massey's  method  of 
cataphoric  treatment  in  malignant  disease.  Litholapaxy  is 
an  introduction  of  recent  years,  and  is  a  great  addition  to  the 
armamentarium  of  the  surgeon.  Aspiration  came  to  us  from 
France,  and  is  one  of  those  methods  so  simple  and  useful,  the 
wonder  is  we  did  not  always  have  it.  Sutures  of  tendons  and 
nerves,  neurectomy,  and  radical  operations  on  the  ear,  breast, 
bones,  and  joints  are  among  the  advances  of  recent  years; 
and  transfusion  of  blood  and  injection  of  normal  serum  are 
in  high  contrast  to  Mackintosh's  bleeding  in  the  cold  stage  of 
ague  and  his  saline  solution  treatment  of  cholera.  The  treat- 
ment of  spinal  deformities  by  application  of  direct  force  is 
very  new,  and  promises  good  results  in  the  young.  Removal 
of  the  entire  larynx  has  become  an  operation  any  surgeon  may 
now  attempt,  for  Billroth  and  J.  Solis  Cohen  have,  among 
others,  established  the  precedent,  and  even  an  artificial  larynx 
has  been  supplied.  The  surgery  of  the  thyroid  has  made  ad- 
vances, and  Green  has  been  a  pioneer  in  method  and  practice. 
I  might  name  many  other  advances  and  improvements  in 
operative  surgery,  but  what  I  have  said  is  sufficient  to  indi- 
cate its  methodical  and  rapid  advance  as  a  science  and  an  art. 

The  hot-air  treatment,  thermotherapy,  is  coming  into  ex- 
tensive use  in  surgery,  and  bids  fair  to  afford  relief  in  selected 
cases,  especially  in  recent  sprains  and  in  many  forms  of  joint 
trouble,  both  acute  and  chronic.  Each  case  is  treated  from 
thirty  to  sixty  minutes,  and  from  one  to  five  heatings  are  used, 
depending  on  the  condition  present.     The  temperature  em- 


FORTY    YEARS    IN    THE    MEDICAT,    PROFESSION 

ployed  runs  from  250^'  to  350''  F.,  or  even  hij^licr.  After  the 
heating  a  protective  dressing  is  applied  and  immediate  use  of 
joint  recommended.  Charles  Lentz  &  Sons,  Philadelphia, 
manufacture  an  efficient  apparatus.  i'Vactures  and  disloca- 
tions are  becoming  more  and  more  generally  and  better  un- 
denstood,  and  the  masterly  work  of  Allis  and  Roberts  and 
Hamilton  has  added  much  to  the  simplicity  of  treatment  aufl 
to  the  attainment  of  good  results.  Indeed,  the  whole  ten- 
dency is  to  simpler  methods  and  less  cumbersome  and  less 
complicated  apparatus,  and  surgeons  are  every  day  beginning 
to  see  and  learn  that  because  a  man  has  a  broken  limb,  he  is 
not  necessarily  to  be  strung  up  and  bound  on  all  sides  like  an 
Indian  papoose  and  made  to  suffer  torture  tenfold  beyond 
what  his  accident  has  imposed  upon  him.  Among  the  great 
improvements  in  apparatus  have  been  the  discarding  of  the 
Physick  Dessault  and  such  splints,  and  their  substitution  by 
sand-bags  and  weights,  with  adhesive  straps  for  extension, 
and  the  throwing  away  of  the  horrible  perineal  band,  and 
substituting  position  to  bring  about  the  counter-extension. 
The  fractures  that  are  common,  and  which  have  given  me 
in  my  experience  the  most  trouble  and  anxiety,  are  those  of 
the  lower  end  of  the  radius,  the  condyles  of  the  humerus, 
which  I  have  often  seen  mistaken  for  a  dislocation,  the  neck 
of  the  femur,  the  clavicle,  the  patella,  and  compound  fractures 
of  all  kinds.  The  jaw  is  frequently  fractured,  and  in  all  con- 
ceivable ways,  but  the  jaw-bone  is  a  wonderful  bone,  and,  as 
the  pugilist  says,  difficult  to  knock  out,  and  often  when  we 
think,  from  the  necessity  of  the  case,  we  will  have  a  bungle 
in  the  cure,  this  grand  old  bone  comes  up  smiling  and  in  good 
shape  and  ready  for  another  round.  The  patella  is  often 
troublesome,  and  wiring  is  now  a  favorite  procedure,  with 
antiseptic  precautions.  The  clavicle  is  especially  apt  to  be 
followed  by  deformity,  and  in  children  is  particularly  hard 
to  hold  with  the  position  of  upward,  outward,  and  backward. 
The  simpler  the  dressing  the  better,  and  this  applies  to  all 
fracture-dressings.  In  compound  fractures  antisepsis  has 
done  wonders  for  us  in  relieving  our  anxiety  and  saving  thou- 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

sands  of  limbs.  In  fractures  at  the  lower  end  of  the  radius, 
be  sure  and  get  in  position  at  once,  the  sooner  the  better  after 
the  accident,  and  you  have  won  half  the  battle.  In  fractures 
of  the  condyles  of  the  humerus  and  of  fractures  involving  the 
elbow- joint,  treat,  as  a  rule,  by  placing  the  arm  in  strong 
flexion  and  keeping  it  there. 

The  Rontgen  rays  are  a  great  help  in  diagnosing  fractures, 
and  the  skiagraph  picture  generally  shows  the  exact  trouble. 
Whilst  it  is  a  boon  to  the  surgeon,  it  may  be  also  a  bane,  for 
doubtless  many  damage-suits  will  be  brought  on  what  it  re- 
veals, whether  the  result  be  good  or  bad,  whether  the  surgeon 
be  fortunate  or  unfortunate,  skilled  or  ignorant. 

In  surgical  and  other  instruments  since  forty  years  there 
has  been  great  improvement  in  quality,  in  style,  and  general 
make-up,  besides  the  introduction  of  a  great  many  new  and 
valuable  inventions.  During  the  decade  between  1850  and 
i860,  Charriere  was  the  great  maker  of  Paris,  and  had  a 
world-wide  reputation  and  clientage,  and  only  second  to  him 
was  Liier,  also  of  Paris.  In  New  York  Tiemann  was  the 
noted  manufacturer,  and  in  Philadelphia  were  Schiveley, 
Gemrig,  Lentz,  Kolbe,  and  others.  Of  all  the  new  instru- 
ments, counting  from  forty  years  back,  there  is  no  doubt  in 
my  mind  as  to  which  has  proved  of  the  greatest  use  and  help 
not  only  to  the  surgeon,  but  to  the  patient  as  well.  This  in- 
strument is  the  little  haemostatic  forceps,  with  the  scissor 
handle  and  the  aseptic  joint.  Take,  for  example,  a  case  of 
excision  of  the  mammary  gland,  and  let  one  follow  a  rapidly 
operating  surgeon,  and  with  the  old-fashioned  tenaculum  and 
forceps  catch  up  the  bleeding  vessels.  You  stick,  you  jab,  you 
pinch,  and  after  a  while  you  get  them,  the  surgeon  or  an  as- 
sistant stops  and  ties,  and  goes  on;  again  you  stick  and  jab 
and  pinch ;  the  surgeon  stops  and  ties  again ;  and  so  on  to  the 
end  of  the  operation.  Much  time  has  been  consumed,  and 
your  patient  has  lost  much  blood,  enough,  indeed,  possibly  to 
turn  the  scale  against  her.  With  the  hsemostat  all  is  changed ; 
the  surgeon  operates  rapidly,  as  a  vessel  bleeds,  the  hsemo- 
stat clicks  in  the  hands  of  an  assistant,  he  drops  it,  the  hem- 

122 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

orrhage  is  cliecked,  and  the  surgeon  goes  on,  and  soon  com- 
pletes his  work.  After  this  he  leisurely  ties  off  and  removes 
the  hasmostat,  and  the  whole  operation  is  finished  and  an 
infinitesimal  amount  of  blood  has  Ijeen  lost.  The  h^emostat 
was  a  gift  to  the  profession  from  the  gynaecologists,  I  think 
from  the  great  French  surgeon  Pean,  and  they  use  them  in 
all  shapes  and  in  all  sizes,  and  thus  save  themselves  much 
wear  and  tear,  control  their  tempers,  and  rescue  many  imper- 
illed lives.  The  Rontgen  rays  are  coming  more  and  more 
into  use  as  aids  to  diagnosis,  both  in  medicine  and  in  surgery, 
and  I  have  by  me  now  a  good  illustration,  where,  among  the 
first  in  this  country,  and  surely  the  first  in  the  State  of  Dela- 
ware, Dr.  William  H.  Hancker,  superintendent  of  the  Dela- 
ware State  Hospital,  at  Farnhurst,  in  the  suburbs  of  New 
Castle,  located  a  ball  in  a  lad's  foot,  a  patient  of  mine,  that 
had  been  buried  there  for  several  years.  At  the  present  time 
it  is  possible  to  obtain  a  skiagraph  of  almost  any  foreign  body 
or  lesion. 

There  has  been  a  general  evolution  of  electrical  devices  to 
the  benefit  of  medicine,  which  it  is  not  necessary  to  refer  to 
here.  In  catheters  there  has  been  marked  improvement,  and 
to-day  the  soft-rubber  instruments  are  effective  for  all  pur- 
poses, and  in  great  contrast  to  the  wretched  metal  devices  of 
years  ago.  Professor  Kelley,  of  Johns  Hopkins,  catheterizes 
the  uterus  and  thus  assists  greatly  in  the  diagnosis  of  renal 
troubles.  The  centrifuge  is  a  great  help  in  microscopic  work, 
and  is  one  of  the  new  and  valuable  instruments  recently  per- 
fected. Uterine  dilators  are  of  many  kinds,  metal  and  rubber, 
and  serve  their  part  as  helps  to  gynaecologists  and  obstetri- 
cians; so  do  cephalotribes,  axis-traction  forceps,  and  differ- 
ent specula;  wires  of  different  metals,  the  animal  ligatures 
and  sutures,  atomizers,  various  new  styles  of  tourniquets,  and 
elastic  bandages  are  among  the  great  helps  to  the  modern 
surgeon  worth  mentioning  in  this  connection.  The  endo- 
scope has  been  in  use  for  some  A^ears.  We  had  it  tried  in 
Blockley  in  1864  in  the  urethra,  but  not  with  great  practical 
success.     The  laryngoscope  was  then  new,  and  Dr.  J.  Solis 

123 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Cohen  first  used  it  in  that  hospital,  and  as  one  of  the  masters 
in  that  work  has  Hved  to  see  its  use  extend  to  all  parts  of  the 
world  where  civilized  man  has  a  foothold.  Different  forms 
of  suspension  apparatus  and  jackets  for  spinal  deformities 
have  come  with  recent  years,  and  are  now  indispensable  in  the 
treatment  of  all  such  troubles,  and  success  has  increased  pari 
passu  with  their  advent.  The  improvement  in  rubber  goods 
has  given  us  very  perfect  stomach-pumps,  stomach  syphon 
tubes,  and  feeding-tubes,  and  these  have  caused  great  ad- 
vances in  the  treatment  of  stomach  ailments  and  in  feeding 
the  recalcitrant  insane  and  those  who  from  any  cause  are  un- 
able to  swallow. 

I  will  speak  of  one  more  instrument,  one  of  the  most  valu- 
able we  possess,  and  one  that  has  done  so  much  to  soothe  the 
pains  and  keep  up  the  courage  of  suffering  humanity,  and 
that  is  the  little  hypodermic  syringe.  The  first  one  I  ever 
owned  I  bought  of  Liier,  in  Paris,  in  1866,  and  to  this  day  it 
has  served  me  well.  It  is  first  class  in  every  respect,  has  gold 
needles,  and  I  have  used  it  continually  in  all  kinds  of  cases,  in 
all  kinds  of  diseases,  and  with  many  and  various  fluids,  and  it 
has  never  failed  me.  I  have  seen  numerous  patterns,  and  have 
several,  one  without  a  piston,  and  easily  made  aseptic,  but  none 
better  than  my  old  Parisian  friend.  During  my  experience  in 
the  United  States  army  of  more  than  two  years,  from  1862  to 
1864,  I  never  saw  one  or  had  seen  one,  and  I  do  not  remember 
that  they  were  on  the  list  of  hospital  supplies.  I  know,  in  Phil- 
adelphia, in  i860,  the  favorite  anodyne  was  an  enema  of  fifty 
drops  of  laudanum  in  a  tabespoonful  of  warm  water  or  thin 
starch,  or  a  rectal  suppository  of  butter  of  cocoa,  with  a  salt  of 
morphia  or  extract  of  opium  or  powdered  opium,  in  combina- 
tion sometimes  with  belladonna  or  some  such  remedy.  Where 
the  hypodermic  syringe  originated  I  do  not  know,  but  I  have  a 
suspicion  that  the  hypodermic  method  of  administering  rem- 
edies was  first  used  by  a  physician  in  Wisconsin  or  Iowa,  or 
one  of  our  northwestern  States;  and  if  so,  he  probably  had 
the  first  instrument. 

The  clinical  thermometer  is  another  instrument  not  appre- 

124 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

ciated  by  those  wlio  have  entered  the  profession  in  recent 
years  as  it  is  l)y  those  who  can  compare  its  every-day  use  with 
the  times  when  we  were  without  its  airl.  ft  is  a  help  of  the 
very  utmost  importance,  as  every  one  knows,  in  the  general 
treatment  of  cases  and  in  diagnosis.  Take  a  case  of  suspected 
appendicitis :  here  the  thermometer  is  our  right-hand  weapon 
in  giving  us  hourly  temperatures,  and  in  from  twenty-four  to 
forty-eight  hours  we  can  almost  allay  or  confirm  our  suspi- 
cions. So  in  suspected  incipient  tuberculous  troubles,  the 
daily  moderate  evening  use  of  temperature,  should  the  case 
present  such  a  chart  for  a  number  of  days,  would  go  far  to  put 
us  on  our  guard  for  further  confirmations. 


125 


CHAPTER    VI. 

Post-Mortems,  etc.,  Forty  Years  Ago — Treatment  of  Pneumonia  Then 
and  Now — Heart-Troubles — Digitalis,  etc. — Auscultation  and  Percus- 
sion— Vivisection — Improvements  in  Pharmacy — Dangers  in  Drugs — 
Sugar-Coated  and  Compressed  Literature — The  Blood — The  Trolley 
— The  Bicycle — Preventive  Medicine — Diagnosis — Wall  Diseases — Ni- 
trification— Malthusian  Theory— Diphtheria — Croup — Sir  Morrell  Ma- 
kenzie — Tetanus — Immunity  as  to  the  Sting  of  the  Honey-Bee. 

Forty  years  ago  there  was  little  known  of  bacteriology  as 
a  science,  and  little  heed  was  taken  of  such  matters  in  medi- 
cine. Pathology  was  in  its  infancy  as  compared  with  the 
present  day,  although  Wiinderlich  and  Rokitansky  were  lay- 
ing the  foundation  for  great  advances  along  all  lines.  In  the 
post-mortems  made  in  the  hospitals  in  this  country  at  the 
period  of  which  we  are  speaking,  say  previous  to  1866,  the 
eye  and  the  touch  were  the  chief  aids  brought  to  bear  in 
examining  specimens. 

There  were  few  expert  microscopists  available,  and  the 
work  done  was  of  the  most  primitive  kind.  Learned  profes- 
sors had  their  own  ideas  and  opinions,  and  these  ideas  and 
opinions  were  generally  derived  from  some  one  equally  em- 
phatic who  had  preceded  them,  probably  amplified  from  time 
to  time  as  light  gradually  began  to  show  itself  on  the  medical 
horizon.  Yet  most  of  their  ideas  and  opinions  had  not  fact, 
scientific  or  otherwise,  for  their  basis,  but  an  absolutely  em- 
pirical origin;  in  other  words,  true  science  had  not  yet 
dawned  upon  medical  practice  and  medical  thought;  and 
this  was  not  long  ago,  either,  but  in  full  memory  of  many 
of  the  most  active  men  in  the  profession  to-day.  The  treat- 
ment of  a  case  of  croupous  pneumonia  at  this  period  will  well 
illustrate  the  condition.  Auscultation  and  percussion  were 
well  understood,  and  the  physical  condition  of  the  lungs 
would  have  been  carefully  noted.     Bleeding  from  the  arm 

had  well-nigh  yielded  as  a  remedy,  but  wet  cups  would  prob- 

126 


FORTY    YEARS    IN    THF^:    MEDICAL    PROFESSION 

ably  have  been  applied  and  veratnim  viride  have  taken  the 
place  of  the  lancet.  The  temperature  wcnild  have  been  judged 
by  the  touch,  if  any  thought  had  been  given  to  it,  and  the 
pulse  at  the  wrist  would  have  been  the  guide  as  to  the  pa- 
tient's condition,  together  with  the  noting  of  the  respiration 
and  the  character  of  the  sputa.  Antimony  would  probably 
have  been  given  in  the  first  stage,  with  the  antiphlogistic  diet, 
but  not  too  much  water.  In  the  second  stage  calomel  and 
opium  would  have  come  in,  and  in  the  latter  part  of  this  stage 
blisters  to  the  involved  lung;  and  after  this  some  increase  of 
nourishment,  and  alcohol,  probably,  to  some  extent,  if  the 
physician  in  attendance  was  an  advanced  thinker.  Note  the 
difference  to-day :  The  physical  and  rational  signs  would  be 
most  carefully  noted,  the  temperature,  as  indicated  by  the 
thermometer,  would  be  scrupulously  watched,  so  the  pulse, 
the  respiration,  the  condition  of  the  skin,  the  stools,  and  the 
sputa,  the  latter  studied  microscopically  and  otherwise.  The 
jacket  poultice,  or,  much  better,  the  dry  jacket,  would  take 
the  place  of  the  wet  cups  and  blisters,  and  ice-bags  might  pos- 
sibly be  applied,  or  cold  sponging.  Strychnine  would  be  used 
as  occasion  required,  and  digitalis  with  scrupulous  care, 
watching  it  when  the  heart  is  weak  and  the  lung  solid ;  with 
alcohol  also,  and  probably  the  inhalation  of  oxygen,  and  pos- 
sibly subcutaneous  injections  of  cultures  of  the  pneumococcus. 

Liquid  air,  or,  rather,  liquefied  air, — which  is  the  air  we 
breathe  deprived  of  its  heat,  which  heat  came  originally  from 
the  sun, — it  is  claimed,  can  now  be  produced  commercially, 
and  this  being  true,  we  can  get  air  absolutely  free  from 
germs,  can  cool  such  apartments  as  hospital  wards  and  keep 
them  at  a  temperature  when  germs  of  contagion  will  not  prop- 
agate, and  if  we  need  the  stimulating  effects  of  an  excess  of 
oxygen  free  from  the  contaminations  which  now  are  so  ob- 
jectionable to  its  practical  use,  we  can  get  it  at  will. 

Now,  as  to  the  difference  in  mortality  between  the  two 
treatments.  Medicine  is  now  a  progressive  science,  and  I  trust 
the  mortality  in  croupous  pneumonia  is  decreasing,  but  it  is 
well  to  remember  it  is  a  self-limited  disease,  and  not  be  too 

127 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

active  in  treatment  in  all  cases.  I  believe  the  sheet-anchor  in 
the  treatment  of  this  disease  to-day  to  be  good,  sound,  dry 
champagne.  If  from  any  cause  the  inky  dry  French  wine 
cannot  be  obtained,  get  the  dryest  American  wine  you  can 
find.  If  this  cannot  be  gotten,  use  the  best  sherry  or  other 
wine  you  can  get  hold  of,  in  equal  parts  of  carbonic  acid 
water.  The  carbonic  acid  gives  zest  to  the  drink,  whatever  it 
may  be,  and  appears  to  me  to  have  some  specific  action  in  all 
diseases  of  the  respiratory  tract. 

As  to  digitalis,  one  of  our  most  useful  remedies,  I  know  of 
no  medicine  which  is  oftener  used  ill  advisedly,  wrongfully, 
and  ignorantly.  To  speak  of  a  remedy  in  heart  lesions,  or 
functional  heart  disturbances  of  any  kind,  is  a  suggestion  to 
many  medical  men  of  digitalis,  with  no  thought  of  scientific 
or  rational  basis  for  its  use.  Improperly  administered,  it  may 
and  perhaps  does  cause  or  hasten  sudden  death.  Take  a  case 
of  aortic  insufficiency :  acting  through  the  motor  ganglia 
of  the  heart,  it  stimulates  the  ventricular  contractions,  thus 
overwhelming  the  heart  by  the  increased  back  current  of 
blood  and  causing  instantaneous  stoppage  and  death.  Thus  a 
man's  chin  drops,  and  he  is  dead  whilst  talking  to  you.  In 
aortic  stenosis  we  probably  always  have  compensatory  hyper- 
trophy; when  this  begins  to  fail,  the  patient's  condition  be- 
comes very  uncomfortable.  Digitalis  may  be  cautiously  ven- 
tured on  here,  for  it  undoubtedly  has  a  tendency  to  hasten 
and  keep  up  compensatory  hypertrophy,  but  I  am  very  chary 
of  it  in  all  lesions  of  the  aortic  valves.  In  pure  hypertrophy 
of  the  heart  never  use  it.  It  increases  blood-pressure  fear- 
fully, and  puts  a  fearful  strain  on  the  capillaries  and  even 
larger  vessels  of  the  brain,  and  the  kidneys  particularly.  Some 
combine  it  with  nitroglycerin  and  strophanthus  to  counteract 
its  force.  Although  strophanthus  itself  lengthens  diastole, 
and  thus  increases  arterial  pressure,  it  does  not  change  the 
caliber  of  the  vessels  through  the  vasomotor  system.  In 
mitral  stenosis  and  mitral  insufficiency  digitalis  is  useful  and 
gives  great  comfort  in  these  distressing  cases  so  often  accom- 
panied by  dropsy  and  cardiac  asthma.     In  mitral  stenosis  the 

1 23 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

orifice  is  narnm^cd,  and  is  thercfcjre  too  small  to  let  out  the 
coliinin  of  blood  that  must  come  through  in  a  given  time, 
therefore  the  heart  struggles  and  hurries  and  wabbles,  of 
course  the  auricle  behind  dilates,  the  right  side  of  the  heart 
becomes  congested,  and  on  the  left  side  the  blood-pressure  is 
lowered.  Here  digitalis  comes  in :  it  gives  force  to  the  ven- 
tricular contractions,  and  thus  does  away  with  the  bad  effect 
of  dilatation ;  diastole  is  also  lengthened,  and  the  auricle  can 
now  have  time  to  empty  itself.  This  action  of  digitalis  is 
also  a  tonic  to  the  heart-muscle  itself  through  the  coronary 
arterial  circulation,  and  helps  over  the  venous  blood  to  the 
red  circulation,  thus  relieving  congestion.  In  mitral  insuffi- 
ciency it  is  also  of  the  greatest  use.  Here  we  want  to  make 
contraction  short,  sharp,  and  decisive,  and  to  lengthen  expan- 
sion. After  this  has  been  accomplished,  in  order  to  check 
the  too  great  effect  of  the  digitalis  in  increasing  blood-press- 
ure, we  may  add  nitroglycerin,  or,  as  Da  Costa  does,  nitro- 
glycerin, belladonna,  and  strophanthus. 

It  has  been  suggested  by  Jacobi  and  other  good  authorities 
to  be  very  careful  of  the  use  of  digitalis  in  the  aged.  Here 
it  has  an  unfavorable  action  on  the  arterioles  of  the  heart, 
interfering  with  its  nutrition,  and  thereby  interfering  with 
the  general  nutrition  of  the  individual.  Combining  it  with 
nitroglycerin  will  in  a  measure  remedy  this  defect. 

My  experience  leads  me  to  look  upon  strychnine  as  the 
great  heart  tonic  to  be  used  in  shock,  and  it  should  be  used  in 
full  doses  subcutaneously.  It  acts  by  stimulating  the  vasomo- 
tor centres,  contracts  the  capillaries,  also  stimulates  the  vagus, 
and  thus  checks  too  rapid  action  of  the  heart.  The  caffeine 
in  coffee  is  a  good  heart  stimulus :  it  tends  to  lessen  the  num- 
ber of  beats  in  palpitation  and  increases  their  force.  It  does 
this,  perhaps,  by  its  action  through  the  vagus.  \'eratrum 
viride  decreases  vascular  tension,  but  is  a  remedy  to  be 
watched  very  closely.  So  nitroglycerin  reduces  blood-press- 
ure and  is  quick  and  rapid  in  its  action,  and  is  a  great  boon 
to  sufferers  from  angina  pectoris  and  other  troubles  caused 
in  part  or  altogether  by  high  blood-pressure.  Aconite  also 
9  129 


FORTY    YEARS   IN    THE   MEDICAL    PROFESSION 

acts  in  the  same  way,  but  is  a  depressant  where  nitroglycerin 
is  a  stimulant  to  the  action  of  the  heart;  and  this  is  most 
important  to  remember.  Nitroglycerin  acts  like  a  strong- 
man at  a  pump  pumping  fluid  through  hose ;  with  his  brawny 
arms  he  rushes  the  pump,  and  by  this  very  force  he  expands 
also  the  hose,  and  thus  the  pressure  is  less  than  it  would  be 
should  a  weaker  man  have  been  at  the  pump,  who  had  not 
strength  enough  to  expand  the  hose,  which  here  may  repre- 
sent the  blood-vessels. 

I  find  the  convallaria  majalis,  the  root  of  the  beautiful  little 
early  spring  flower,  the  lily  of  the  valley,  an  efifective  heart 
tonic,  and  very  useful  in  weak  persons  who  are  subject  to  at- 
tacks of  palpitation,  or  where  there  may  be  a  suspicion  of  fatty 
heart.  It  and  strophanthus  make  a  most  useful  combination. 
In  the  very  common  trouble  of  intermitting  heart  of  a  purely 
functional  nature, — not  the  irregular  heart,  which  is  a  very 
different  thing, — a  combination  of  strophanthus  and  con- 
vallaria will  add  to  the  tone  of  the  heart  where  such  a  remedy 
is  needed,  and  is  far  preferable  to  digitalis,  so  often  in- 
advisedly used  under  these  conditions.  I  know  little  of  spar- 
teine or  broom-corn  from  personal  experience,  but  would  be 
inclined  to  use  it  in  hysterical  palpitation.  Quebracho  bark 
has  been  vaunted  as  a  remedy  in  dyspnoea,  but  repeated  trials 
have  always  failed  to  produce  any  effect  whatever  in  my 
hands.  The  one  generally  used  is  the  white  quebracho,  Aspi- 
dosperma  quebracho.  Quebracho  gum,  the  dried  juice  of 
Schinopsis  Lorent,  two  drachms,  might  be  more  effective  by 
increasing  the  oxygen  in  the  blood-cells.  In  aortic  regurgi- 
tation,— one  of  the  most  difficult  forms  of  valvular  heart  trou- 
ble to  make  out  by  the  ear,  I  think,  but  comparatively  easy 
when  the  additional  symptoms  of  attacks  of  dyspnoea  come 
on, — cactus  is  the  remedy.  It  shortens  and  makes  systole 
more  snappy,  lets  up  the  blood-pressure,  and  makes  the  beats 
fewer.  This  is  what  we  want  in  this  most  serious  trouble. 
These  patients  may  also  drink  strong  coffee,  as  the  effect 
of  the  caffeine  will  be  good,  and  cocaine  is  not  contraindi- 
cated;   but  look  out  for  general  anaesthesia.     When  we  give 

130 


FORTY    YEARS    JN    'I'lIE    MEDICAL    I'KOI' ICSSION 

<)])iiini,  wc  increase  tlie  l)l()(i(l  pressure,  and  with  ergot  vvc 
do  the  same  and  decrease  tendency  to  capillary  hemorrhage 
by  its  stimulating  action  on  the  vasomotor  nerves;  but  some 
deny  this.  When  we  wish  to  lessen  the  force  and  frequency 
of  the  pulse  and  lower  arterial  tension,  we  take  the  nitrites, 
the  bromides, — particularly  the  strontium  bromide, — and  the 
antipyretics,  and  thus  gain  the  wonderful  control  we  now  pos- 
sess over  annoying  and  distressing  troubles  like  angina  pec- 
toris, which  formerly  we  and  our  patients  had  to  grin  and 
bear. 

Speaking  of  angina  pectoris,  my  experience  leads  me  t(j  the 
belief  that  it  is  most  common  among  those  who  live  sedentary 
lives  and  do  much  brain-work.  I  believe  it  is  more  common 
among  students,  literary  and  professional  men,  than  other 
people,  and  it  is  especially  common  among  those  who  apply 
themselves  more  or  less  constantly  to  desk  work,  the  local 
pressure  here  possibly  acting  as  a  cause.  The  Schott  treat- 
ment of  heart  disease  by  carbonic  acid  baths  and  muscular 
movements  is  creating  some  stir  in  Germany,  probably  more 
general  than  professional  stir.  I  have  had  no  experience 
with  it,  nor  can  I  altogether  imagine  its  rationale.  One  thing 
remember :  in  all  cases  of  organic  heart  trouble,  the  first  and 
greatest  of  all  remedies  is  rest  of  mind  and  body,  and  as  near 
perfect  rest  as  it  is  possible  to  attain  in  the  given  case;  and 
next  to  rest,  the  proper  climate  for  the  individual,  where  his 
environment  gives  us  a  choice  of  a  mode  of  life. 

Well,  pardon  me,  I  did  not  start  out  to  write  a  treatise  on 
therapeutics,  but  such  matters  are  of  the  first  importance,  and 
we  cannot  give  them  too  much  thought  to  insure  the  safety 
and  comfort  of  those  committed  to  our  care. 

Whilst  auscultation  and  percussion  have  been  elaborated  in 
different  ways  both  by  men  famous  in  these  specialties  and 
by  the  invention  and  adaptation  of  new  instruments,  we  are 
to-day  not  much  more  exact  in  our  diagnoses  than  were 
Avenbrugger,  who  invented  percussion  as  applied  to  the  diag- 
nosis of  disease,  and  Laennec.  who  invented  auscultation. 
Their  work  has  been  carried  on  by  such  men  as  Andral,  Louis. 

131 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

and  Skoda,  in  Europe,  and  by  Cammann,  Gerhard,  Da  Costa, 
and  others  in  this  country.  Laennec's  original  instrument 
was  a  single  cylinder,  and  is  the  instrument  that  has  been 
used  most  in  America.  Cammann  invented  the  double  in- 
strument. I  started  with  this  in  my  student  days,  and  have 
always  used  and  preferred  it.  It  is  now  gaining  in  favor, 
which  gain  may  be  much  ascribed  to  the  fact  that  so  accom- 
plished and  able  a  diagnostician  as  Osier,  of  Johns  Hopkins, 
recommends  and  uses  it.  A  recent  invention,  the  phonendo- 
scope,  with  some  of  its  principles  modelled  after  the  tele- 
phone, is  coming  into  use,  and  I  can  testify  from  personal 
experience  that  it  is  of  great  use  in  differentiating  sounds, 
and  making  diagnoses  in  many  cases  easy.  Auscultatory  per- 
cussion is  growing  in  favor.  I  have  used  it  myself  for  many 
years.  It  can  only  conveniently  be  practised  with  the  binau- 
ral stethoscope.  After  all,  we  become  accustomed  to  different 
methods  and  different  instruments,  and  of  course  we  become 
prejudiced  in  favor  of  those  old  friends  who  have  served  us 
well  for  a  long  time,  and  are  conservative  as  to  adopting  new 
tools.  This  is  the  great  reason  why  many  really  great  im- 
provements are  slow  of  finding  general  favor. 

With  the  introduction  of  auscultation,  percussion,  and  other 
and  various  methods,  the  diagnosis  of  disease  became  the  most 
fascinating  part  of  medical  study,  and  everything  else  yielded 
to  it.  What  little  attention  had  been  paid  to  pathology,  his- 
tology, microscopy,  and  therapeutics  especially  were  neg- 
lected. The  great  aim  of  the  physician  was  to  become  an 
accurate  and  acute  diagnostician.  Skoda  was  the  great  leader 
in  Europe.  Alonzo  Clark,  Austin  Flint,  Gerhard,  and  Da 
Costa,  and  later,  Musser  and  Osier,  in  this  country.  I  re- 
member hearing  it  said  of  one  of  these  eminent  men,  that 
when  asked  why  he  did  not  write  a  work  on  practice,  he  re- 
plied, he  could  not  do  it.  for  the  treatment  of  disease  he  con- 
sidered so  imsatisfactory  he  could  not  conscientiously  advise 
in  such  matters  in  a  work  on  the  practice  of  medicine. 

Even  so  great  a  man  as  Marion  Sims  had  little  faith  in 
remedies.     I  remember  of  hearing  that  his  medical  adviser 

132 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

and  friend,  a  few  days  before  his  sudden  death,  suggested 
that  he  take  some  prescription  for  the  heart  lesion  from  which 
he  was  suffering.  Sims  replied,  "  No,  1  have  Httle  or  no 
faith  in  remedies."  But  medicine  is  a  progressive  science 
now,  not  a  mere  empirical  art,  as  it  once  was,  and  not  long 
ago  either,  and  happily  this  era  of  therapeutic  nihilism  is  rap- 
idly passing  away,  not  from  fashion,  not  as  a  fad,  but  it  has 
been  driven  to  the  wall  by  the  onward  march  of  progress  and 
reform.  We  are  learning  much  from  chemistry,  from  physi- 
ology, experimental  and  otherwise,  and  from  nature  gen- 
erally, and  great  credit  is  due  to  men  like  Horatio  Wood, 
Hare,  Welch,  Vaughan,  and  many  others  for  the  great  work 
they  have  done  and  are  doing  in  practical  therapeutics  and 
practical  physiology. 

There  is  an  ill-advised  movement  now  on  foot  engineered 
by  many  good  people  with  mistaken  zeal  to  pass  an  act  against 
vivisection.  If  any  wanton  cruelty  is  practised  by  men  en- 
gaged in  such  experimental  work,  there  is  ample  law  now 
possessed  by  the  Society  for  the  Prevention  of  Cruelty  to 
Animals.  In  this  work  there  is  no  wanton  cruelty,  but  it 
would  be  wanton  cruelty  personified  if  the  knowledge  that  has 
been  gained  from  such  work  and  applied  for  the  relief  of 
suffering  in  man  should  be  cast  off  among  the  lost  arts  and 
no  longer  be  available  for  the  use  of  physicians.  Where  would 
intestinal  surgery  be,  where  would  be  our  knowledge  of 
serumtherapy,  or  where  would  be  all,  or  nearly  all,  we  know 
of  bacteriology,  which  as  it  expands  is  surely  leading  to  the  an- 
nihilation of  all  zymotic  diseases  which  are  now  the  great  fac- 
tors in  sapping  the  lives  of  the  fairest  and  often  the  younger 
and  most  useful  of  the  human  race  ?  The  honest  vivisection- 
ist  works  not  for  any  selfish  motive ;  of  all  men,  such  experi- 
menters are  usually  the  most  unselfish.  Many  of  them  live 
in  garrets,  and  their  most  elaborate  repast  is  frequently  a 
crust.  They  have  none  of  the  motives  urged  on  by  insatiate 
ambition  and  pride,  such  as  Willis  ascribes  to  Parrhasius 
when  he  makes  him  say  as  he  looks  upon  the  writhings  of  his 
poor  old  slave,  whom  he  is  torturing  to  death,  the  better  to 

^35 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

get  the  expression  of  hopeless  horror  with  which  to  adorn  his 
great  painting,  Prometheus,  whom  he  was  about  to  paint : 

"  '  Pity'  thee  !    so  I  do  ! 

I  pity  the  dumb  victim  at  the  altar, 
But  does  the  robed  priest  for  his  pity  falter? 
I'd  rack  thee  though  I  knew 

A  thousand  lives  were  perishing  in  thine : 
What  were  ten  thousand  to  a  fame  like  mine?" 

Not  on  these  hues  does  the  scientific  man  work,  but  his  only 
ambition  is  to  induce  nature  to  give  up  the  secrets  she  may 
hold  inimical  to  the  health  and  comfort  of  man,  and  in  this 
great  and  noble  work,  practising  constant  restraint  and  self- 
denial,  he  asks  no  reward  beyond  honest  recognition  and  a 
free  and  untrammelled  going  out  and  coming  in  among  men, 
such  as  is  accorded  to  the  meekest  and  most  lowly  among  us. 

Pharmacy  and  chemistry  as  applied  to  manufacturing  have 
made  great  strides  in  the  last  few  years.  The  active  princi- 
ples of  medicines,  being  of  very  small  bulk,  are  now  dispensed 
in  little  tablets  of  almost  infinitesimal  size,  and  are  in  great 
contrast  to  the  great  powders  and  pills  and  boluses  of  former 
days.  Think  of  a  dose  of  quinine,  and  then  think  of  the  dose 
of  ground  bark  your  grandfather  had  to  take  to  get  the  equiv- 
alent of  the  alkaloid  in  your  small  tablet.  Pharmaceutical 
preparations  now  are  really  artistic  and  beautiful  to  look  at. 
and  I  have  no  doubt  when  honestly  prepared  are  far  more 
efficient  than  those  prepared  by  the  old  methods.  There  is 
one  danger,  and  by  no  means  an  insignificant  one,  and  that  is 
the  palatable  and  attractive  way  preparations  are  put  upon 
the  market  containing  stimulating  remedies,  such  as  opium, 
cocaine,  kola,  alcohol,  and  so  on  ad  infinitum.  Physicians 
cannot  be  too  careful  in  prescribing  such  dangerous  drugs. 
Unfortunately  the  physician  controls  only  a  small  part  of  the 
output  of  such  preparations.  The  general  public  takes  them 
self-prescribed,  or  recommended  by  the  vender,  and  thus  the 
modern  drug-store  becomes  an  element  of  danger  to  the  com- 
munity, second  only  to  the  modern  saloon.  These  matters 
need  attention.   No  proprietary  preparation  containing  opium, 

134 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

alcohol,  cocaine,  or  such  dangerous  flrug,  should  be  sold  with- 
out the  fact  of  the  amount  of  each  in  each  prescribed  dose 
being  plainly  printed  on  the  wrapper.  Many  good  people 
would  stand  in  horror  did  they  see  such  information  on  what 
they  are  often  buying  and  taking  now  as  harmless  "  liver  reg- 
ulators" or  innocent  "  blood-searchers."  In  fact,  in  many  of 
them  they  get  a  good  morning  eye-opener,  a  mid-day  cock- 
tail, or  a  composing  night-cap  in  each  dose;  whether  it  be 
composed  of  opium,  chloral,  alcohol,  cocaine,  or  what  not,  it 
brings  the  answer,  and  the  poor  deluded  dupe  is  soon  on  the 
road  to  some  form  of  intemperance,  with  all  that  the  name 
implies.  However,  quackery  and  quack  doctors  have  always 
existed,  and  probably  will  continue  to  thrive  until  the  people 
are  better  informed  and  better  educated  in  all  that  pertains 
to  the  good  and  comfort  of  their  bodies,  the  depth  of  their 
pockets,  and  the  salvation  of  their  souls. 

It  is  humiliating  nowadays  to  pick  up  many  of  our  daily 
newspapers.  Many  of  the  most  prominent  ones  have  adver- 
tisements in  them  that  are  utterly  immoral,  utterly  obscene, 
and  utterly  unfit  to  come  into  the  home  of  any  decent  man; 
indeed,  some  of  them  are  unfit  for  the  abode  of  strumpets. 
The  pictures  of  so-called  distinguished  men,  of  governors  of 
States,  of  Congressmen  and  clergymen,  are  especial  favorites 
in  the  picture  column.  Could  anything  be  more  vulgar? 
Could  anything  be  lower  or  more  common?  God  save  us 
from  such  rulers,  God  protect  us  from  such  influences,  and 
purify  at  least  in  some  small  degree  the  newspaper  press  of 
the  world  !  The  literature  put  out  by  the  great  manufacturing 
drug-houses  is,  some  of  it,  very  good,  well  written,  well  di- 
gested, and  gotten  up  by  bright  men,  and,  making  due  allow- 
ance for  the  exaggeration  of  zeal  for  trade,  is  useful  to  the 
profession,  notwithstanding  it  has  frequently  been  railed  at 
and  derided  as  worthless  and  worse  than  worthless,  and  as 
literature  both  sugar-coated  and  compressed,  and  warranted 
not  to  pass  the  alimentary  canal  undissolved. 

Many  men  in  the  profession  have  little  time  to  read,  and 
do  not  take  what  time  they  have:    some  have  no  books,  and 

135 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

are  unable  to  buy  them ;  some  will  not  read.  These  little 
brochures  scattered  about  promiscuously  from  time  to  time 
by  the  great  drug-houses  fill  a  want  among  these  people  and 
disseminate  much  useful  information. 

Among  the  remedies  introduced  since  I  entered  medicine, 
amyl  nitrite  strikes  me  as  one  of  the  most  useful.  If  it  did 
no  more  than  relieve  the  pain  and  anguish  of  angina  pectoris, 
it  would  be  an  invaluable  remedy,  and  we  owe  much  to 
Brunton,  the  great  English  physician,  for  having  found  out 
its  merits  in  this  distressing  disorder.  It  also  gives  instant 
relief  in  those  cases  of  hysteria  where  w^e  find  the  patient  suf- 
fering acutely  with  the  bolus  hystericus,  or  with  the  convul- 
sive form.  A  few  whiffs  from  a  few  drops  on  a  handker- 
chief, a  sudden  flushing  of  the  face,  and  the  storm  is  over. 
In  true  functional  spasmodic  asthma  it  is  also  effectual  and 
safe,  and  in  the  spasmodic  pain  of  dysmenorrhoea  and  allied 
troubles. 

Nitroglycerin,  trinitrin,  or  officially  U.  S.  P.  glonoin,  is  a 
new  remedy  of  great  usefulness  and  power.  It  serves  about 
the  same  purposes  as  amyl  nitrite,  but  is  more  capable  of  gen- 
eral use,  by  the  mouth  and  so  on.  In  weak  heart,  in  asthma, 
and  in  convulsive  troubles  it  is  a  wonderful  remedy,  and  can 
be  used  whenever  we  need  to  lower  the  blood-pressure.  The 
new  antipyretics — the  so-called  coal-oil  derivatives,  antipyrin, 
acetanilide,  phenacetin,  and  such  like — have  proved  great 
boons  to  the  medical  man,  and  have  given  him  effective 
weapons  with  which  to  control  many  ills  both  great  and 
small,  and  whilst  in  the  hands  of  the  profession  they  have 
done  great  good,  done  away  with  Dover's  powder,  sweats, 
and  all  such  abominations  of  the  by-gone  days,  yet,  neverthe- 
less, they  have  been  subjected  to  great  abuse  by  laymen,  and 
doubtless  are  responsible  for  many  deaths  not  directly  traced 
to  them.  Every  drug-store,  and,  for  that  matter,  even  many 
bar-rooms,  have  them  for  sale  to  any  one  coming  in  under 
the  guise  of  Dr.  Somebody's  headache  powders,  and  guaran- 
teed to  be  harmless.  These  preparations,  above  all  others, 
should  not  be  taken  without  proper  supervision,  and  their 

136 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

promiscuous  sale  should  be  stoi)])cd.  I  can  testify  from  per- 
sonal experience  to  the  p^ood  effect  oi  antipyrin  in  strong 
solution  as  a  h.'emostatic  in  nose-bleed,  bleeding  after  tooth 
extraction,  etc. 

The  introduction  of  the  ductless  j^^lands  is  also  recent,  and 
wonders  have  been  accomplished  in  myxcedcma  by  thynjid 
feeding.  It  has  also  been  used  in  certain  forms  of  insanity, 
but  success  to  any  extent  has  not  followed  this  use  of  the 
thyroid,  and  the  same  may  be  said  of  its  use  in  syphilitic  skin 
affections;  yet  I  believe  I  would  try  it  in  these  troubles  if  un- 
yielding, and  also  in  obesity,  with  proper  diet,  if  it  amounted 
to  a  disease.  I  have  seen  it  do  wonders  in  leg  ulcers.  The 
thymus  gland  is  also  used  as  a  remedy,  but  little  success  has 
as  yet  come  from  it.  The  suprarenal  capsules  are  used  in 
Addison's  disease,  and  success  enough  has  been  recorded  to 
give  us  hope  in  a  hitherto  hopeless  malady.  The  nose  and 
throat  men  are  also  using  it  as  a  haemostatic  in  their  opera- 
tions. The  mammary  gland  has  been  recommended  in  the 
treatment  of  uterine  fibroids,  and  the  parotid  gland  has  been 
used  for  the  cure  of  ovarian  disease.  These  applications  will 
doubtless  be  further  elaborated.  Indeed,  all  sorts  of  gland- 
feeding  appears  to  be  going  on,  spurred  up  by  the  recommen- 
dations of  the  late  Browii-Sequard,  with  the  result  that  a  ten- 
dency to  quack  the  whole  business  has  come  about  and  thus 
for  a  time  done  injury  to  true  scientific  investigation  and 
application. 

Of  all  the  introductions  of  remedies  into  the  profession 
since  my  advent  into  it,  that  of  serum  therapy  has  been  the 
most  far-reaching,  and,  being  based  on  true  scientific  princi- 
ples, is  the  most  astounding.  I  do  not  propose  to  discuss  this 
theme  here,  but  will  speak  of  it  more  at  length  farther  on. 
Nitrous  oxide  gas  has  been  introduced  within  a  few  years, 
and  has  proved  a  great  boon  to  those  compelled  to  have  teeth 
extracted,  and  may  be  used  in  minor  surgical  operations  of 
short  duration.  My  experience  leads  me  to  decry  its  use 
where  we  want  muscular  relaxation,  as  in  the  operation  for 
fistula  in  ano,  for  the  sphincters  are  rigid,  not  relaxed  under 

13; 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

nitrous  oxide  gas,  and  this  rigidity  embarrasses  us  in  such 
operations.  Sahcyhc  acid,  sodium  saHcylate,  salol,  and  stron- 
tium saHcylate  have  been  wonderful  acquisitions  to  one  who 
was  compelled  to  treat  rheumatism  particularly,  and  also  gout 
and  uricacidaemia  generally  by  the  old  remedies.  Rheuma- 
tism had  about  exhausted  the  pharmacopoeia,  and  rheumatic 
fever  often  meant  from  three  to  six  weeks'  suffering,  not  to 
speak  of  the  sequelae.  I  find  strontium  salicylate,  while  less 
soluble,  to  agree  in  some  cases  better  than  sodium  salicylate, 
and  vice  versa.  Why  I  know  not,  but  the  same  thing  occurs 
with  potassium  iodide  and  sodium  iodide.  In  rheumatism  I 
appear  to  get  the  best  and  quickest  results  from  ten-grain 
doses  of  the  salts,  sodium  salicylate,  or  strontium  salicylate, 
given  in  capsule  or  mixture.  If  in  mixture,  add  sufficient 
liquor  ammonise  acetatis  to  clear  the  liquid.  Horatio  Wood 
recommends  giving  salicylic  acid  in  officinal  oil  of  gaulthe- 
ria  in  ten-  to  fifteen-minim  doses.  In  gout  this  acts  well. 
I  am  fond  of  a  capsule  containing  twenty  centigrammes  of 
methyl  salicylate,  C7  f^^  ^  O3,  and  one-quarter  of  one  milli- 
gramme of  colchicine.  I  always  like  a  little  colchicum  with 
the  salicylates  in  gout.  Two  of  these  may  be  given  at  a  dose 
as  occasion  requires.    They  are  a  French  preparation. 

Carbolic  acid  has  been  introduced  of  late  years,  and  is  so 
useful  in  many  ways,  and  another  contribution  from  the  won- 
derful coal-tar.  Trional  and  sulphonal  are  great  helps,  which 
we  who  were  in  the  profession  twenty-five  or  more  years  ago 
had  to  do  without.  Now  with  their  use  we  can  give  a  patient 
comfortable  and  safe  sleep,  where  before  we  had  only  opium 
and  its  salts,  whose  sequelae  are  so  seriously  annoying,  and 
chloral,  and  even  this  last  does  not  go  back  far.  As  between 
trional  and  sulphonal,  I  prefer  in  every  respect  trional.  If 
there  is  great  pain,  add  a  grain  or  two  of  svapnia  or  a  modi- 
cum of  codeine.  Formaldehyde  is  a  recent  addition  as  an 
antiseptic,  but  mostly  used  under  the  name  of  formalin.  Ho- 
ratio Wood  says  formalin  is  a  forty  per  cent,  aqueous  solution 
of  formaldehyde.     Merc's  formaldehyde  is  a  forty  per  cent. 

solution  of  formaldehvde  also,  and  therefore  the  same  as  for- 

138 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

malin,  which  is  a  proprietary  preparation,  and  therefore  more 
expensive.  When  you  order,  order  merely  a  simple  solution 
of  formaldehyde.  One  to  twenty  with  water  will  give  you  a 
two  per  cent,  solution,  strong  enough  for  surgical  work ;  one 
to  forty  a  one  per  cent,  solution,  strong  enough  for  gargles 
or  mouth-washes,  or  for  applications  t(j  abrasions  and  skin 
troubles,  as  a  rule.  A  ten  per  cent,  solution  will  harden  speci- 
mens for  section  for  microscopical  work.  After  using  for- 
malin or  formaldehyde,  two  per  cent,  in  surgical  work,  1  find 
it  difficult  to  remove  blood-stains  at  once,  but  they  disappear 
in  a  few  hours,  and  everything  looks  clean.  It  is  doubtless 
a  strong  germicide  in  even  one  per  cent,  solutions,  but  whether 
or  not  it  will  entirely  take  the  place  of  heat  and  corrosive  sub- 
limate and  other  aids  in  surgical  work,  my  experience  with  it 
being  limited,  I  cannot  venture  an  opinion.  I  trust  it  will,  for 
it  will  save  much  trouble  and  make  antisepsis  and  asepsis 
easier  and  more  pleasant. 

Horatio  Wood,  in  the  last  edition  of  his  "  Therapeutics," 
speaks  of  formal-gelatin,  brought  forward  by  Dr.  C.  L. 
Schleich,  as  a  valuable  wound-dressing.  It  is  non-irritant, 
non-poisonous,  and  when  brought  in  contact  with  wounds 
undergoes  decomposition  with  the  liberation  of  formalde- 
hyde, and  the  consequent  complete  destruction  of  all  septic 
organisms.  This,  if  effective,  would  be  a  grand  addition  to 
the  armamentarium  of  the  surgeon. 

As  long  as  I  can  remember,  the  great  tonic,  and  the  one 
almost  universally  in  use,  has  been  a  combination  of  iron, 
quinine,  and  strychnine.  The  formation  of  a  proper  portion 
of  haemoglobin  in  the  red  blood-corpuscles  was  thought  to 
depend  on  the  amount  of  iron  taken  up  by  the  corpuscles. 
There  is  a  disposition  among  physiological  chemists  to  deny 
that  inorganic  iron  salts  are  absorbed,  that  they  do  not  appear 
in  the  urine,  and  that  all  go  off  in  the  fecal  discharges,  which 
they  blacken  by  meeting  with  sulphur  in  the  alimentary  debris. 
These  same  chemists  claim,  of  course,  that  iron  organically 
combined,  as  in  foods,  is  absorbed  sure.  Thus  claiming,  these 
men  have  gotten  up.  and  are  getting  up,  preparations  of  iron 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

organically  combined.  Such  preparations  are  dried  blood, 
nncleo-albumins,  hepatica-ferruginous  preparations,  and  such. 
Extended  trial  has  not  yet  convinced  me  that  inorganic  iron 
does  not  in  some  way  influence  the  red  blood-corpuscles  for 
good,  and  I  am  not  yet  convinced  that  the  new  preparations 
are  any  more  effectual,  if  as  effectual,  as  the  inorganic  salts. 
Let  me  say  here  that  continued  use  of  these  new  preparations 
of  iron  and  iron  and  manganese,  as  the  peptonized  albuminates 
and  such,  organically  combined,  is  beginning  to  give  me  great 
confidence  in  them  in  many  diseases,  particularly  of  the 
wasting  diseases,  and  I  begin  to  feel  that  we  have  a  thera- 
peutic weapon  more  powerful  than  any  we  have  even  dreamed 
of  before,  which  is  destined  to  supersede  all  the  inorganic 
salts  of  iron  and  such  materials.  If  this  is  true,  real  science 
is  driving  out  ignorance  and  mere  conjecture. 

Tincture  of  chloride  of  iron  and  Basham's  mixture  are  the 
best  forms  of  giving  inorganic  iron,  to  my  mind,  and  the 
tincture  of  the  chloride  given  in  milk  is  among  the  greatest 
of  all  organic  tonics.  Drop  the  iron  in  a  little  water  first,  then 
add  to  milk,  and  it  will  not  coagulate,  and  is  pleasant  to  take. 
Remember  one  thing :  used  in  any  way  it  is  hard  on  the  teeth, 
should  be  taken  through  a  tube  run  far  back  in  the  throat, 
and  the  mouth  should  at  once  be  rinsed  with  an  alkaline  wash. 

Piperazin  is  a  new  remedy  recently  introduced,  and  one 
which  my  slight  experience  in  its  use  leads  me  to  think  is  a 
valuable  addition  to  the  Pharmacopoeia.  I  have  no  faith  in 
its  dissolving  stone  already  formed  in  the  bladder,  unless  it 
might  be  brought  about  by  injecting  directly,  although  it  soon 
passes  by  the  kidneys.  I  am  now  using  it  in  a  case  of  diabetes, 
where  strictly  non-starchy,  non-saccharine  diet  cannot  be  kept 
up.  Since  giving  it  in  five-grain  doses  three  times  a  day,  the 
specific  gravity  has  fallen  to  1028  and  1029,  where  before, 
under  the  same  conditions,  it  ranged  at  1035  or  over.  It  is 
supposed  to  check  some  of  the  sugar-forming  influences  on 
some  of  the  blood  ferments,  I  believe.  I  used  it  with  great 
apparent  success  in  the  most  exaggerated  and  persistent  case 
of  uric  acid  gravel  I  ever  encountered.     For  several  years 

140 


FORTY    YEARS    IN    Tfll-     MEDICAL    PROFESSION 

a  orentleman  of  forty,  at  the  commencement  of  liis  trouble, 
had  attacks  of  renal  colic  every  two  or  three  months.  He 
was  temperate  as  to  drink,  but  intemperate  as  to  diet  for  one 
afflicted  as  he  was.  I  have  known  him  to  pass  seventy  small 
calculi  of  uric  acid  in  one  attack,  and  altojji-ether  T  am  afraid 
to  say  how  many  he  passed,  but  a  very  larj^e  number.  .After 
this  had  been  going  on  for  several  years,  1  put  him  on  j)ipera- 
zin,  five  grains,  three  times  a  day,  in  water  on  an  empty  stom- 
ach. He  took  it  steadily  for  nearly  six  months,  then  stopped 
two  months,  then  took  it  again  occasionally  for  a  week  or 
two  at  a  time,  and  then  stopped  it  altogether.  He  only  had 
one  attack  after  he  commenced  the  remedy,  and  now  has  not 
had  an  attack  for  over  two  years,  and  has  not  been  careful 
with  his  diet  either.  It  acted  as  a  diuretic  moderately  with 
him,  darkened  the  urine,  and  reduced  somewhat  the  quantity 
of  urea.  No  bad  or  unpleasant  symptom  of  any  kind  resulted 
from  its  use. 

These  uric  acid  cases  are  such  peculiar  cases ;  a  man  is  too 
vigorous,  as  it  were,  to  be  healthy,  the  very  opposite  of  the 
feeble  anaemic  man,  as  can  be  so  readily  shown  now  by 
our  improved  methods  of  diagnosis  in  estimating  the  blood- 
strength  as  to  its  corpuscles  and  other  constituents,  all  of 
which  is  so  readily  shown  by  the  improved  microscopes,  the 
hsemocytometers,  the  hsematokrits,  the  h^emoglobinometers. 
and  so  on,  instruments  and  methods  we  who  entered  the  pro- 
fession forty  years  ago  never  dreamed  of.  The  hsemoglobin 
of  the  blood,  of  course,  may  be  lessened  by  the  lessening  of 
the  number  of  red  corpuscles  or  of  the  coloring-matter  of  the 
red  corpuscles,  and  an  easy  test  of  the  amount  of  haemoglobin 
is  by  the  specific-gravity  test,  a  table  of  which  Dr.  E.  Barker, 
the  pathologist  at  the  Delaware  State  Hospital  at  Farnhurst 
has  kindly  prepared  for  me.  Mix  chloroform  and  benzole  to 
make  a  specific  gravity  of  1059.  about  that  of  normal  blood. 
Chloroform  is  heavier  than  blood,  and  benzole  is  lighter. 
Drop  a  drop  of  blood  from  a  pipette  into  the  mixture  of  chlo- 
roform and  benzole.  If  the  drop  sinks  to  the  bottom,  add 
more  chloroform ;  if  it  rises  to  the  top.  add  more  benzole  until 

141 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

the  drop  remains  stationary  in  the  body  of  the  Hquid.  Now 
note  the  specific  gravity  of  the  Hquid,  and  this  denotes  the 
specific  gravit}^  of  the  drop  of  blood.  Have  all  instruments 
clean,  and  add  chloroform  and  benzole  drop  by  drop,  stirring 
with  a  glass  rod.    This  test  is  not  reliable  in  cases  of  dropsy. 

.SCALE. 

Specific  Gravity 

of  Liquid.  Haemoglobin. 

1033  to  1035  gives 25  to  30  per  cent. 

1035  to  1038  gives 30  to  35  per  cent. 

1038  to  1040  gives 35  to  40  per  cent. 

1040  to  1045  gives 40  to  45  per  cent. 

1045  to  1048  gives 45  to  55  per  cent. 

1048  to  1050  gives 55  to  65  per  cent. 

1050  to  1053  gives 65  to  70  per  cent. 

1053  to  1055  gives 70  to  75  per  cent. 

1055  to  1057  gives 75  to  85  per  cent. 

1057  to  1060  gives 85  to  95  per  cent. 

Dr.  William  H.  Hancker,  Superintendent  of  the  Delaware 
State  Hospital  at  Farnhurst,  has  given  me  an  outline  of  a 
method  of  determining  approximately  the  deficiency  in  the 
red  blood-corpuscles  which  is  simple  and  useful.  The  glass 
tube  of  the  centrifuge  is  graduated  to  100;  on  turning  it,  say, 
two  and  one-half  minutes,  the  red  corpuscles  will  gravitate  to 
one  end.  If  it  registers  50,  or  about  one-half  of  the  entire 
amount,  the  blood  is  proximately  normal,  or  between  five  and 
six  millions  of  red  corpuscles  to  one  cubic  centimetre.  If  it 
goes  below  that,  the  reading  can  readily  be  understood.  In 
other  words,  if  the  red  corpuscles  show  only  to  about  25,  it 
means  that  the  red  corpuscles  are  only  about  one-half  the 
quantity  they  ought  to  be. 

The  practical  application  of  the  Rontgen  rays,  already 
spoken  of,  to  medical  diagnosis  is  merely  dawning,  and  time 
alone  can  tell  of  the  perfection  to  which  it  will  be  brought. 
It  is  not  safe  to  predict  that  we  may  not  soon  be  able  to  see 
clear  through  a  stone  wall.  The  centrifuge  is  another  little 
instrument  of  great  use  and  recent  introduction,  and  adds 
greatly  to  our  exactness  in  the  examination  of  all  fluids.  The 
aspirator  is  another  great  help,  from  the  little  hypodermic 

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FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

syringe,  which  often  makes  a  very  good  one  for  (hagnostic 
purposes,  to  the  one  large  enough  to  aspirate  the  larger  cavi- 
ties of  the  body.  We  are  indebted  to  the  French  for  this  in- 
strument, the  invention  of  Dieulafoy. 

The  great  discoveries  in  electricity  and  its  application  to 
medicine  have  been  of  great  help  in  many  ways.  I  look  upon 
the  introduction  of  the  trolley  as  a  wonderful  therapeutic 
agent.  It  is  a  cheap  and,  with  its  steady,  even  motion,  a  very 
pleasant  way  of  getting  about.  It  is  a  great  factor  in  per- 
suading sedentary  people  to  breathe  fresh  air,  to  mingle  with 
the  crowd,  and  to  take  at  least  passive  exercise.  To  a  man 
or  woman  fatigued  by  a  hard  day's  work,  and  perhaps  weak- 
ened and  enervated  by  excessive  heat,  a  fanning  up  by  an 
hour's  ride  in  the  trolley  has  a  wonderfully  refreshing  effect : 
the  tired,  nervous  feelings  vanish,  and  sleep  comes  readily, 
bringing  renewed  strength  for  the  work  of  to-morrow.  One 
thing  beware  of, — the  trolley  cold  is  so  often  taken  in  the  open 
car.  As  a  rule,  this  can  always  be  avoided  by  wearing  a  silk 
handkerchief  around  the  neck  whilst  in  motion,  and  never 
getting  on  the  car  when  perspiring.  The  electric  fans  are  also 
of  great  use  for  general  comfort,  and  especially  so  in  the  hos- 
pital or  sick-room.  Be  cautious  here,  and  avoid  drafts  from 
these  sources  also. 

The  bicycle,  too,  I  look  upon  as  a  great  therapeutic  factor 
when  used  rationally  under  medical  supervision.  We  are 
bound  to  see  the  effects  of  its  use  apparent  in  the  coming  man 
and  woman.  The  bank  clerk,  the  stenographer,  and  such 
persons  now  have  some  resource  for  recuperation  after  long 
hours  of  incessant  labor,  and  a  ride  on  the  wheel  sends  them 
home  not  exhausted,  but  rehabilitated  in  mind  and  body,  their 
organic  functions  are  kept  active,  and  the  channels  of  excre- 
tion and  secretion  are  no  longer  clogged  for  want  of  the 
proper  stimulation  of  healthy  exercise.  Another  great  factor 
in  improving  the  health  of  communities,  and  thus  reducing 
the  death  list,  is  the  improvement  in  the  water  supply  of  cities 
and  towns,  and  even  of  individual  premises. 

The  driven  wells,  in  place  of  the  old-fashioned  large  dug 

143 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

■wells,  are  a  great  improvement  in  the  low  countries ;  surface 
contamination  is  thus  avoided  and  pure  water  is  more  easily 
obtained.  The  extensive  filtering-plants  now  being  put  in  by 
cities  are  moves  in  the  right  direction,  and  the  results  are  very 
encouraging  in  decreasing  the  prevalence  of  zymotic  disease 
where  such  plants  have  been  in  operation.  There  is  yet  onl}'- 
one  way  to  have  water  absolutely  safe,  and  that  is  to  boil  it 
to  absolute  sterility ;  but  filtering — through  sand  particularly 
— undoubtedly  removes  many  and  great  dangers. 

The  intelligent  physician,  especially  in  communities  re- 
moved from  centres,  should  have  supervision  over  all  these 
matters  appertaining  to  the  economies  of  life.  Indeed,  I 
think  one  of  the  great  factors  in  the  usefulness  of  the  physi- 
cian will  be  in  preventive  medicine.  In  public  matters  that  is 
now  making  great  strides,  but  I  refer  particularly  to  the  re- 
lation to  families  in  private  life.  All  families  should  be  under 
the  supervision  of  an  intelligent  all-round  medical  man.  All 
the  environments  of  the  home  should  be  supervised ;  the  en- 
vironments of  the  individual  should  be  supervised ;  then  the 
physician  will  know  in  time  and  have  some  warning  of  the 
approach  of  many  illnesses  and  be  able  to  warn  those  inter- 
ested. As  it  is  now,  often  we  are  summoned  to  some  fair 
youth  with  a  report  from  parents  that  a  bad  and  persistent 
cold  is  the  only  trouble,  when  examination  reveals  a  broken- 
down  lung,  and  a  condition  of  well-advanced  pulmonary  tu- 
berculosis, and  the  case  almost  hopeless  as  far  as  remedies  are 
concerned.  With  competent  supervision  of  a  medical  man 
over  that  family,  observation,  with  the  finding  of  a  slight  rise 
in  the  thermometer  every  evening,  would  have  called  atten- 
tion to  the  true  trouble  months  or  years  before,  and  this  early 
finding  out  of  the  cause  gives  the  only  shadow  of  hope  in  these 
sad  cases.  Such  a  case  illustrates  the  necessity  of  such  gen- 
eral medical  supervision  of  families,  and  herein  rests  one  of 
the  great  usefulnesses  of  the  physician,  and  in  this  sphere  he 
is  bound  to  work  more  and  more  as  the  evolution  of  a  perfect 
civilization  progresses. 

The  physician,  of  course,  naturally  should  be  an  observant 

144 


FORTY    YEARS    IN    THE    MEDICAE    PROFESSION 

man  above  all  others,  and,  more  than  this,  he  should  cultivate 
habits  of  the  nKjst  careful  observation.  It  is  very  easy  to  be 
tripped  up  in  diagnosis  by  very  simple  matters,  and  practice 
alone  makes  perfect,  but  practice  does  not  help  unless  backed 
up  by  acute  observation  and  general  knowledge.  No  obscure 
case,  in  fact  few  cases,  should  be  treated  without  a  thorough 
examination  of  the  urine.  No  one  but  the  physician  knows 
how  much  knowledge  of  cases  we  gain  here.  What  woful 
mistakes  are  made  by  a  neglect  of  this  procedure,  not  only  in 
missing  the  direct  cause  of  the  disease  in  question,  but  also  in 
showing  up  collateral  troubles  and  complications  to  give  cases ! 
How  depressing  to  meet  a  case  of  renal  asthma,  for  instance, 
and  find  it  has  been  treated  for  every  other  disease  which  may 
possibly  cause  dyspnoea  except  the  right  and  proper  one! 
How  often  do  we  have  patients  consult  us,  who  are  just  a 
little  under  the  weather  and  want  a  little  medicine  to  set  them 
up,  and  on  investigation  we  find  a  contracted  kidney  and  all 
which  that  implies !  How  humiliating  to  be  called  in  consul- 
tation for  a  case  of  obstruction  of  the  bowels,  and  a  thorough 
examination  reveals  a  strangulated  hernial  tumor  as  the  cause ; 
and  how  terrible  it  would  be  should  it  have  passed  beyond  the 
time  of  successful  relief ! 

In  my  experience,  latent  syphilis  is  the  cause  of  a  great 
deal  of  obscure  disease ;  indeed,  syphilis  is  a  protean  disease, 
and  how  often  in  its  latent  form  it  is  overlooked,  and  in  most 
cases  how  satisfactory  the  treatment!  In  nervous  syphilis 
what  wonders  we  see !  I  was  once  called  to  a  fine  young  fel- 
low under  thirty,  and  found  him  helpless  on  the  floor  with  a 
complete  hemiplegia.  Under  thirty  and  a  paralytic !  I  at 
once  knew  the  trouble, — only  syphilis,  or  metallic  poisoning 
once  in  a  thousand  cases,  and  by  all  odds  syphilis.  A  history 
of  the  case  soon  revealed  syphilis  as  the  origin  of  his  trouble 
and  enabled  me  to  venture  a  favorable  prognosis.  In  a  few 
months  he  was  about,  and  in  tw'o  years  was  a  strong,  vigorous 
man,  with  directions  whenever  he  was  sick,  even  from  a  bad 
cold,  to  always  tell  his  attending  physician  he  was  or  had  been 
a  syphilitic,  and  thus  get  proper  treatment  at  an}'  time.  Large 
10  145 


FORTY   YEARS    IN    THE   MEDICAL    PROFESSION 

doses  of  the  iodides  saved  him.  How  many  such  cases  are 
sacrificed  to  ignorance  and  pretence ! 

Many  mistakes  in  diagnosis  are  made  in  malarial  diseases. 
Latent  malaria,  both  civic  and  paludal,  are  very  common  dis- 
eases, and  the  therapeutic  test  with  the  alkaloids  of  cinchona 
unmasks  very  many  of  them,  and  the  microscope  is  still  more 
effectual.  There  are  many  complications  between  typhoid 
fever  and  other  diseases,  but  in  my  experience  it  is  well  to  be 
very  careful  and  not  mistake  appendicitis,  tuberculous  dis- 
ease of  different  forms,  trichina  spiralis,  melancholia,  renal 
troubles,  and  malarial  troubles.  Remember  that  diabetics 
under  thirty-five  are  apt  to  be  tuberculous,  so  be  careful  to 
be  on  your  guard  and  differentiate  here  between  the  diabetes, 
tuberculosis,  and  typhoid  fever.  Are  there  mingled  types  of 
fever,  for  example,  typho-malarial  fevers?  The  prevailing 
opinion  in  the  profession  appears  to  be  against  this  mingling 
of  fever  types.  I  do  not  know,  surely ;  probably  no  one  does ; 
I  do  know  thg-t  the  autumnal  fevers  prevalent  on  the  Dela- 
ware and  Chesapeake  peninsula  act  in  many  cases  like  true 
enteric  fever,  with  a  true  mingling  of  malarial  invasion,  and 
full  antiperiodic  doses  of  the  alkaloids  of  cinchona  are  neces- 
sary for  their  control  and  successful  treatment.  The  Civil 
War  started  this  discussion  as  to  fevers,  and  the  present  war 
may  do  much  to  further  elucidate  the  subject. 

The  more  I  see  of  our  autumnal  fevers  of  the  Middle  and 
Southern  States,  which  are  usually  diagnosed  as  enteric  fever, 
and  which  are  many  of  them  such  as  were  spoken  of  during 
the  Civil  War  as  typho-malarial,  the  more  I  am  convinced 
there  is  in  these  cases  something  more  than  the  ordinary  case 
of  typhoid  or  enteric  fever.  There  is  a  malarial  complication, 
or  some  complication  more  than  malarial,  which  will  at  some 
future  day  be  explained.  There  is  in  these  cases  evidently  to 
me,  as  it  were,  some  auto-intoxication  due  to  tissue  waste,  or 
some  such  trouble,  possibly  to  one  or  more  of  the  pathogenic 
germs  occupying  the  intestinal  tract.  If  no  mingling  of  the 
fevers,  there  must  be  a  mingling  of  the  causes  of  these  cases 
more  than  the  one  cause  producing  true  enteric  fever,  and 

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FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

these  mingled  cases  may  be  due  to  a  mingling  of  malarial  or- 
ganisms, of  typhoid  organisms,  of  unicellular  animalcules, 
together  with  the  bacillus  coli  communis  and  its  attendant 
evils;  thence  follows  a  mingled  fever;  why  not? 

Just  now,  whilst  writing  these  lines,  1  understand  they 
have  discovered  at  the  Pepper  Laboratory  of  the  University 
of  Pennsylvania  the  plasmodium  malarias  in  the  blood  of  a 
case  of  a  well-marked  enteric  fever,  where  the  typhoid  rash 
was  thoroughly  developed  and  identified.  Of  course,  in  this 
patient  there  must  have  been  a  malarial  explosion  within 
twenty-four  hours,  to  have  found  Laveran's  characteristic 
organism.  I  am  not  surprised  at  this  discovery;  it  only  con- 
firms views  I  have  long  held  on  this  subject.  From  experi- 
ments made  in  new  countries,  Paget  concludes  that  the  ty- 
phoid bacillus  exists  in  virgin  soil,  but  it  requires  educating, 
— that  is,  to  be  transferred  through  a  series  of  hosts, — before 
it  produces  typhoid  fever.  The  so-called  typho-malarial  fever, 
he  thinks,  is  produced  by  the  typhoid  bacillus  before  it  has 
gone  through  these  various  hosts.  This  is  quite  a  pretty 
theory,  but  the  day  of  theories  in  medicine  is  fast  passing 
away,  and  giving  way  to  exact  science.  My  friend  Dr.  Rich- 
ard Woods  has  kindly  given  me  the  hospital  record  of  the  case 
of  mingled  fever  referred  to,  as  follows : 

J.  McK.,  twenty-three  years  old,  single,  admitted  to  Uni- 
versity Hospital  September  9,  1898.  Previous  history  nega- 
tive ;  was  first  at  Camp  Alger  and  then  transferred  to  Camp 
Meade.  Previous  to  admission,  headache,  lassitude,  pain  in 
back,  etc. ;  enlarged  spleen ;  rose-colored  spots ;  bronchitis ; 
iliac  tenderness;  plasmodium  malarise  found  in  the  blood. 
Widal  test  present.  Highest  temperature,  104.6°  F.  Had 
a  chill  following  admission.  Quinine  given,  and  no  recur- 
rence of  the  chill.     Discharged  October  10,  1898. 

The  microscope  will  help  out  as  the  Widal  sero-diagnosis 
becomes  more  generally  accessible,  and  the  spirillum  in  re- 
lapsing fever  now  makes  that  clear,  as  does  the  malarial  or- 
ganism in  malarial  fever.  In  regard  to  the  malarial  organism, 
there  are  probably  three  different  kinds,  and  the  recurrence 

147 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

of  the  chills  and  fevers  is  believed  to  be  caused  by  a  large 
number  of  the  parasites  coming  to  maturity  at  once.  Thus 
we  have  the  quotidian  type  of  parasite,  the  tertian  type,  and 
the  quartan  type,  each  taking  a  different  length  of  time  to 
complete  its  maturity,  and  then  the  storm  comes.  These 
bodies  destroy  the  red  corpuscles  and  thus  produce  anaemia, 
and  as  they  pass  on  in  their  life  pigment  bodies  are  developed 
in  them,  which  are  picked  up  by  the  white  blood-corpuscles 
and  destroyed,  and  probably  our  specific  remedies,  as  quinine, 
act  through  these  white  blood-corpuscles  and  thus  destroy 
the  organisms.  As  to  their  life  history  and  hosts  we  know 
very  little.  Some  such  organisms  have  been  found  in  some 
birds,  and  the  mosquito  has  been  suggested  as  a  host.  Some 
use  for  the  mosquito,  anyhow,  if  true,  even  if  a  bad  use. 

Nothing  shows  the  rapid  advances  in  the  study  of  medical 
science  more  than  the  unfolding  of  our  knowledge  in  refer- 
ence to  the  malarial  parasites,  and  in  treating  malarial  dis- 
eases it  behooves  us  to  take  heed  of  the  results  furnished  us 
by  the  scientists  to  be  at  all  successful.  Osier  claims  malaria 
to  be  the  only  disease  for  which  we  have  absolute  specifics. 
We  will  find,  as  we  treat  cases,  that  all  the  types  of  the  organ- 
ism do  not  yield  to  bark  alone,  but  require  additions  of  other 
remedies.  Dr.  Charles  Dewey  Center,  of  Illinois,  has  given 
us  a  good  resume  of  the  subject.  In  1879  Lewis  discovered 
a  malarial  parasite.  Laveran  made  his  discovery  in  1880. 
Thayer  claims  it  is  not  a  single  and  polymorphous  organism, 
but  the  three  forms  represent  distinct  varieties :  ( i )  There 
is  a  variation  arising  from  difference  in  the  parasites;  (2) 
a  variation  of  individual  dififerences ;  ( 3 )  variation  of  place 
and  season;  (4)  variation  as  to  what  remedies  have  been 
used  or  omitted. 

If  we  recognize  the  quotidian  organism  of  Golgi,  which  is 
not  yet  admitted  by  all,  there  are  four  forms  of  the  organism, 
— the  quotidian,  which  gives  attacks  every  twenty-four  hours, 
and  may  possibly  not  be  a  distinct  species,  but  a  mixed  species 
of  the  other  three;  the  tertian,  the  quartan,  and  the  crescent, 
or  estivo-autumnal,  the  name  denoting  its  time  of  appearance, 

148 


FORTY    YEARS    IN    THE    MEDICAE    PROFESSION 

from  (cslds,  siininicr,  and  auliiumus,  autnnin.  My  experience 
in  looking  for  these  parasites  shows  it  of  importance  to  recog- 
nize the  type  from  the  symptoms,  and  in  all  cases  it  is  proba- 
bly important  to  use  the  microscope  as  soon  after  the  chill  or 
explosion  as  possible,  and  not  to  delay  in  any  case  over  a  few 
hours.  The  flagellae  are  active  in  all  forms,  and  are,  accord- 
ing to  Koch,  the  spermatozoa.  They  all  inhal)it  the  blood. 
The  crescent  lives  in  the  blood  chiefly  of  the  bone  marrow  and 
the  spleen,  and  this  form  produces  probably  relapsing  fever, 
pernicious  fever,  and  the  irregular  malarial  fevers.  The 
practical  point  to  bear  in  mind  is  the  remedy  for  each  form  of 
malarial  fever,  depending  on  the  examination  of  the  blood  by 
the  microscope  at  the  proper  time,  thus  showing  us  the  organ- 
ism we  have  to  treat,  whether  it  be  the  quotidian,  the  tertian, 
the  quartan,  or  the  crescent  or  estivo-autumnal.  The  differ- 
ent alkaloids  of  bark  are  probably  specifics  for  the  first  three 
types,  but  if  we  do  not  add  arsenic  to  the  bark  alkaloid  we 
will  fail  in  treating  the  crescent  form.  There  is  where  we 
probably  often  fail  in  our  treatment  of  stubborn  cases.  Of 
course,  when  I  say  bark,  I  mean  Peruvian  bark.  In  spleen 
cases  and  in  cases  where  we  have  the  fearful  bone-aches,  head- 
aches, and  nausea,  we  likely  will  not  succeed  with  bark  alone, 
but  will  succeed  wath  arsenic  and  bark,  and  with  the  iodides 
and  iodine  and  bark,  and  such  remedies. 

Especially  since  our  newer  and  nearer  relations  to  the  home 
of  yellow  fever,  we  may  often  be  embarrassed  in  our  diagno- 
sis of  fevers.  Take  a  case  of  a  man  on  our  first  seeing  him 
with  coma,  jaundice,  and  high  temperature,  probably  from  a 
yellow  fever  district ;  bacteriolog}'  is  the  only  help  to  save  us 
from  embarrassment.  The  presence  of  a  malarial  organism 
and  the  absence  of  the  bacillus  icteroides  would  go  far  to  clear 
up  the  diagnosis.  Whether  these  organisms  coexist  in  the 
same  individual  has  probably  not  yet  been  determined,  but  it 
looks  as  though  the  bacillus  icteroides  had  been  defined  as  the 
cause  of  yellow^  fever. 

Now^  for  antitoxins  or  specific  remedies  in  all  of  these  pests. 
I  believe  the  tertian  malarial  organism  to  be  the  one  found 

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FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

generally  in  the  Middle  States  and  upper  Southern  and  West- 
ern States.  We  do  not  often  see  the  quartan  on  the  Delaware 
and  Chesapeake  peninsula.  In  the  tropics  and  in  the  jungles 
look  out  for  the  crescent  form  with  all  of  its  horrors,  and  re- 
member we  may  find  it  well  to  the  north  too. 

Let  me  repeat,  when  we  have  a  case  of  malarial  fever,  and 
find  the  quotidian,  tertian,  or  quartan  organism,  we  will  at 
once  relieve  the  case  by  a  mercurial  purge  and  one  of  the 
alkaloids  of  bark,  followed  at  proper  intervals  by  bark  salts 
to  prevent  a  recurrence,  and  then  by  attention  to  a  proper 
change  of  environment  and  general  tonics.  Let  the  estivo- 
autumnal  or  crescent  parasite  be  present,  and  you  will  surely 
need  arsenic  added  to  your  bark  salts,  and  probably  iodine 
and  the  iodides.  It  is  a  common  belief  in  our  extreme  South- 
ern States  that  if  a  person  run  down  by  malarial  fever  goes 
to  the  mountains  he  will  most  probably  develop  typhoid  fever. 
Can  this  be  so,  and  what  is  the  relation  here?  The  Western 
mountain  fever  is  probably  an  enteric  fever. 

Another  link  in  the  chain  in  the  diagnosis  of  enteric  fever 
is  Ehrlich's  reaction,  or  the  diazo  reaction,  as  pointed  out  to 
me  by  Dr.  E.  Barker,  now  of  the  State  Hospital  at  Norris- 
town,  Pennsylvania.  Tyson  gives  full  directions  for  this  test 
in  his  "  Practice  of  Medicine,"  and  says  it  is  symptomatic,  not 
diagnostic,  certainly  not  pathognomonic,  as  it  occurs  in  many 
diseases  with  high  fever,  among  which  measles  and  miliary 
tuberculosis  are  conspicuous.  If  not  present,  the  case  is  prob- 
ably not  typhoid  fever.  In  typhoid  fever  it  appears  from  the 
fifth  to  the  fourteenth  day,  and  disappears  later  on.  There  is 
one  important  point :  it  is  said  sometimes  to  appear  in  malarial 
fever.  These  are  probably  cases  of  typho-malarial  fever,  as 
we  now  know  such  to  exist.  The  cause  of  typhoid  fever  is 
now  generally  recognized  as  the  bacillus  of  Eberth,  and  it  is 
found  in  many  parts  of  the  body  besides  the  intestines,  as  in 
the  blood,  the  mesenteric  glands,  the  spleen,  the  gall-bladder, 
and  even  in  the  rose-colored  spots.  It  is  often  found  in  the 
fecal  discharges,  and  here,  of  course,  is  diagnostic,  if  the  pa- 
tient has  fever.    The  bacilli  have  been  known  to  live  in  water 

150 


FORTY    YEARS    IN    TIIJC    MEDICAL    PROFESSION 

three  months,  in  soil  six  months.  They  have  been  known  to 
have  Hved  in  a  vacuum  over  two  hundred  days ;  in  fact,  they 
are  most  tenacious  of  hfe.  Sunh'ght,  next  to  lieat,  is  most 
destructive  to  them.  What  effect  electric  h^ht  rays  may  liave 
on  them  I  do  not  know.  This  effect  of  hght  is  a  practical 
point ;  keep  the  house  open  to  the  sun,  and  air  all  dark  corners. 
Why  houses  are  ever  built  with  cellars  I  do  not  know.  I 
do  not  think  the  coming  man  will  be  fool  enough  to  dig  a 
hole  as  a  resort  and  home  for  all  kinds  of  germs,  pathogenic 
and  other  kinds,  and  then  build  his  house  over  such  a  pest- 
breeder. 

The  bacillus  of  typhoid  fever  enters  the  system  of  man 
most  frequently  through  milk  and  water,  but  it  may  enter 
through  any  kind  of  food  or  drink,  or  with  the  dust  from 
rooms  or  other  sources  by  inhalation.  The  bacillus  of  Eberth 
and  the  bacillus  coli  communis  have  been  found  together  in  a 
room  where  typhoid  fever  had  existed  months  before.  I  be- 
lieve the  Eberth  bacillus  can  be  inhaled  from  sinks  and  such 
places  containing  contaminated  dejecta;  at  least,  I  have  prac- 
tical reasons  for  thinking  so. 

It  is  possible  to  spread  the  bacillus  to  soil  and  water-courses 
by  spreading  night  soil,  but  I  have  practised  medicine  a  long 
time  in  a  community  where  the  night  soil  from  seventy  thou- 
sand people  is  spread  on  the  soil  of  the  suburban  surround- 
ings, and  although  I  have  watched  this  point  closely,  I  cannot 
say  the  people  in  this  neighborhood  suffer  from  typhoid  fever 
to  a  greater  extent  than  those  living  on  other  farm  lands.  I 
may  remark  here  that  my  experience  with  the  application  of 
cold  in  typhoid  fever  has  been  very  satisfactory,  both  by  bath 
and  by  cold  sponging,  but  in  private  practice,  as  cases  usually 
occur  to  us,  the  use  of  the  bath  is  so  inconvenient  to  patient 
and  attendants  as  almost  to  prohibit  its  use  and  drive  us  to 
cold  sponging  and  other  means  of  applying  cold,  as  the  cold- 
air  current,  etc.  Thayer  has  shown  that  after  a  Brand  bath 
the  leucocytes  are  doubled,  or  more  than  doubled,  and  that  the 
medicinal  antipyretics  have  the  effect  of  decreasing  the  leuco- 
cytes, and  we  all  know  how  they  depress  the  heart.    Believing 

iSi 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

siich  testimony,  no  one  can  fail  to  choose  the  Brand  method, 
or  some  modified  form  of  it,  and  Hmit  decidedly  the  use  of 
medicinal  antipyretics,  though  not  absolutely,  as  undoubtedly 
small  doses  of  acetanilide  are  often  safe  and  most  useful. 
Some  claim  the  high  temperature  is  only  evidence  of  the  com- 
bustion of  the  materies  morbi,  the  germs.  Beware!  do  not 
let  the  high  temperature  go  to  the  point  of  roasting  the  host 
whilst  it  cooks  his  guest. 

As  to  the  antiseptic  treatment  of  typhoid  fever  by  intestinal 
antisepsis,  neither  my  reason  nor  my  experience  has  led  me  to 
give  it  my  unqualified  approval.  If  the  pathogenic  germs  be 
alone  and  only  in  the  intestinal  tract,  we  might  reach  them. 
In  a  healthy  individual,  the  normal  intestinal  fluids  being  anti- 
septic and  germicidal,  there  is  little  or  no  need  of  germicides 
from  without.  When  we  see  a  person  ill  with  typhoid  fever 
for  the  first  time,  the  pathogenic  germ  has  long  before  doubt- 
less left  the  intestinal  tract  and  is  swarming  in  the  spleen,  the 
liver,  the  blood,  and  other  parts.  Can  these  be  reached  by  a 
small  dose  of  an  antiseptic  administered  per  orem?  Most 
probably  not.  Such  practice  leads  to  empiricism  and  routine 
practice, — a  pellet  for  this  and  a  pellet  for  that.  God  save 
the  intelligent  physician  from  such  methods !  Notwithstand- 
ing this,  I  usually  give  an  antiseptic  in  typhoid  fever.  It  may 
reach  some  of  the  pathogenic  germs  in  the  intestinal  tract, 
and  if  salol  is  used,  it  splits  up  into  carbolic  and  salicylic  acids, 
and  may  even  act  farther  on  as  a  germicide,  but  I  doubt  it.  I 
scarcely  believe,  for  instance,  such  can  sterilize  the  blood. 
There  is  one  use  for  intestinal  antisepsis  in  typhoid  fever 
where  I  advocate  it  ardently  for  its  local  action, — in  the  sec- 
ondary cases,  we  may  call  them,  where  the  case  has  apparently 
run  its  course  and  is  going  on  to  recovery,  but  recovery  does 
not  come.  In  these  cases  we  have  probably  an  example  of 
auto-intoxication,  caused  by  poisonous  ptomaines,  alkaloids, 
or  what  not,  generated  in  the  alimentary  tract.  The  proper 
treatment  here  is  undoubtedly  antiseptics  locally  applied,  per 
orem,  and,  if  necessary,  per  rectum.  These  are  the  post- 
typhoid fever  cases  some  authors  speak  of.     Watch  them 

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FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

keenly.  Constipation  from  milk  diet  may  be  the  cause;  the 
causes,  especially  in  young  uatients,  may  be  purely  nervous. 
Above  all  things,  watch  for  the  creeping  upon  your  ])atient  of 
some  tuberculous  trouble.  Occasionally  laryngeal  trtjubles 
come  on  in  the  later  stages  of  typhoid  fever.  They  may  be 
inflammatory  and  run  a  usual  course.  Again,  they  may  not 
be  inflammatory  at  all,  but  a  true  paralysis  of  the  laryngeal 
muscles,  particularly  of  the  posterior  crico-arytenoid  and  lat- 
eral crico-arytenoid  muscles.  The  muscles  paralyzed  cannot 
perform  their  functions  of  widening  the  glottis  by  relaxing 
the  vocal  cords,  and  thus  breathing  may  be  greatly  interfered 
with  or  stopped  altogether.  Tracheotomy  is  usually  necessary 
in  these  cases,  and  the  tube  may  possibly  need  to  be  worn  a 
long  time,  or  even  indefinitely. 

I  look  with  some  hope  for  the  victims  of  typhoid  fever 
from  inoculation  from  cultures  of  the  pathogenic  germ,  Pfeif- 
fer's  and  Jez's  bactericidal  serum,  accounts  of  which  are  just 
beginning  to  be  whispered  towards  medical  circles.  Even  the 
blood-serum  of  convalescents  from  the  fever  is  being  used. 
Typhoid  fever  is  mildly  contagious,  doubtless,  and  for  this 
reason  patients  should  be  isolated  as  much  as  possible,  and  put 
in  absolute  aseptic  surroundings.  Disinfect  stools  and  urine 
with  chlorinated  lime  one  pound,  and  carbonate  of  soda  two 
pounds,  to  the  gallon  of  water.  This  is  Labarraque's  solution, 
or  very  near  it,  and  years  ago  I  have  seen  it  sell  for  one 
dollar  for  a  bottle  holding  less  than  one  quart.  Cover  all  dis- 
charges with  this  and  allow  them  to  stand  thus  covered  for 
three  hours,  and  they  will  then  be  aseptic.  If  this  is  not  done, 
flies  wall  surely  convey  the  pathogenic  germ.  I  am  sure  fever 
is  often  spread  in  this  w^ay,  especially  where  many  human 
beings  are  congregated,  as  in  camps.  Keep  the  defecating 
and  urinating  organs  of  the  patients  aseptic  externally.  As  a 
rule,  do  not  give  your  patient  animal  broths,  they  are  culture 
media  for  the  pathogenic  germ,  and  should  not  be  used  as 
food  for  typhoid  patients.  Watch  your  patients  keenly,  feed 
them  liberally  with  liquids  and  semi-solids  only;  be  particu- 
lar not  to  starve  them ;   especially  giA'e  them  now"  and  again 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

hot  coffee  or  tea,  if  they  crave  it ;  do  not  spare  alcohol  when 
needed ;  it  is  not  always  needed ;  and  above  all  things  do  not 
over-drug  your  patients. 

Such  methods  as  the  foregoing  have  been  very  successful 
with  me.  If  symptoms  of  perforation  appear  and  they  be 
verified,  there  is  only  one  slight  hope, — promptly  appeal  to 
surgery.  Not  all  cases  of  typhoid  fever  have  diarrhoea.  This, 
I  think,  is  more  apparent  in  later  years,  showing  the  distribu- 
tion of  the  pathogenic  germ  from  some  cause  to  be  more 
general  in  the  system  and  not  so  thoroughly  confined  to  the 
intestinal  tract.  I  doubt  if  three-fourths  of  the  cases  have  it, 
but  in  every  case  of  typhoid  fever,  where  there  is  no  diarrhoea, 
or  even  where  there  may  be  constipation,  you  give  a  mild 
cathartic  and  you  will  have  excessive  action  of  the  medicine 
as  a  diagnostic  sign,  as  a  therapeutic  test. 

In  my  early  professional  life  I  was  always  taught  to  avoid 
purgatives  in  typhoid  fever  as  I  would  avoid  poison,  and  I 
cannot  conceive  but  that  the  eliminative  treatment  by  purga- 
tives, as  advocated  by  Dr.  Thistle,  may  be  accompanied  by 
great  danger.  Such  treatment  cannot  get  rid  of  all  the  germs, 
for  they  are  not  all  in  the  tract  swept  by  the  purgative,  and  the 
local  lesions  cannot  help  but  be  greatly  disturbed  by  constant 
irritations  set  up  by  the  cathartics.  I  have  never  seen  the  re- 
sult of  a  post-mortem  in  one  of  these  cases,  nor  proved  one 
bacteriologically,  where  there  was  no  diarrhoea.  Diarrhoea 
is  the  serious  symptom  and  its  sequelae,  and  the  case  is  serious, 
as  a  rule,  as  the  diarrhoea  is  serious,  and  I  suppose  the  diar- 
rhoea is  serious  as  the  intestinal  lesions  are  serious. 

In  my  experience  I  have  only  seen  two  undoubtedly  thor- 
oughly authenticated  cases  of  typhoid  fever  occurring  in  the 
same  individual  twice.  Both  cases  were  young  men.  In  both 
the  first  attacks  were  very  severe.  In  one  there  was  a  compli- 
cation of  phlegmasia  alba  dolens.  The  attacks  in  both  were 
about  three  years  apart;  the  last  attacks  were  mild  in  every 
way,  but  marked ;  the  effect  of  the  first  attacks  appeared  to 
me  to  establish  at  least  some  tolerance,  but  to  establish  no  im- 
munity, at  least  after  three  years  had  intervened.     Another 

154 


FORTY    YEARS    TN    TTTR    MROICAL    PROFESSION 

point  in  typlioid  fever :  the  diagnosis  may  be  obscure,  because 
some  cases  run  only  a  few  days  and  are  very  lij:?lit,  with  no 
symptoms  beyond  a  furred  tongue  and  general  malaise,  no 
diarrhoea,  enlarged  spleen,  or  rose  spots.  The  Widal  test  will 
usually  differentiate  these  cases.  These  may  be  ambulant 
cases  and  scatter  the  pathogenic  germs  by  their  urine  and 
fecal  discharges,  and  thus  distribute  the  disease  through  camps 
and  such  places.  Such  cases  exist,  so  be  on  your  guard.  We 
may  have  also  what  Osier  calls  acute  typhoid  septicaemia,  cases 
overwhelmed  by  the  pathogenic  germs.  Here  we  have  intense 
headaches,  furious  mania,  and  even  cerebro-spinal  convul- 
sions. The  Widal  test  is  our  resource  again  here.  Beware 
of  the  cases  in  which  you  have  jaundice.  Here  the  pathogenic 
germ  has  invaded  the  gall-bladder  and  set  up  a  toxaemia,  local 
and  general.  Intestinal  hemorrhage  and  epistaxis  are  com- 
mon in  these  cases,  and  death  is  the  usual  outcome  with  these 
complications. 

Dr.  C.  N.  B.  Camac,  of  New  York  City,  has  given  us  a 
classical  essay  on  the  involvement  of  the  gall-bladder  in  ty- 
phoid fever.     (See  Johns  Hopkins  Bulletins.) 

Whilst  on  this  subject  let  me  say  something  of  the  use  of 
saline  infusion,  or  normal  salt  solution.  The  true  normal 
salt  solution  approaching  nearest  to  the  blood-serum  is  seven- 
eighths  of  one  per  cent.  I  have  seen  some  reports  of  its 
successful  use  by  merely  throwing  it  into  the  large  bowel  in 
threatened  collapse  from  hemorrhage,  etc.,  in  typhoid  fever. 
Anyhow,  it  is  wonderful,  even  by  our  old  methods,  how 
many  cases  of  hemorrhage  from  the  bowels  in  this  fever  re- 
cover. This  method  is  worth  trying.  Dr.  Thomas  E.  Reilly. 
of  New  York  City,  has  given  us  the  best  paper  on  the  tech- 
nique and  use  of  saline  infusions.  He  gives  ninety-two  grains 
of  ordinary  table  salt  to  a  quart  of  water  as  making  a  solution 
of  six-tenths  per  cent.  For  all  practical  purposes,  one  tea- 
spoonful  to  one  pint  of  water  will  make  the  normal  solution. 
and  I  think  is  the  easiest  to  remember.  Now  boil  and  filter 
the  solution.  In  using  the  solution  have  it  at  a  temperature 
of  1 00°  F.     The  ways  of  getting  this  into  the  system  are  by 

155 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

the  veins  or  the  arteries  subcutaneously,  and  by  injections 
into  the  bowels.  I  should  say  that  even  into  the  peritoneal 
cavity  might  be  worthy  of  trial.  Whichever  way  it  goes,  use 
absolutely  antiseptic  precautions,  even  if  used  per  orem. 

In  advanced  heart  disease  do  not  use  the  method  by  the 
blood-vessels.  By  the  subcutaneous  method  attach  an  aspi- 
rating needle  to  a  Davidson's  syringe  or  to  a  fountain  syringe, 
or,  as  Dr.  H.  A.  Kelly  suggests,  by  reversed  aspiration;  and 
I  see  no  reason  why  the  old-fashioned  antitoxin  syringes 
might  not  do.  Put  the  fluid  into  the  loose  connective  tissue  of 
the  abdomen,  the  axilla,  under  the  breasts.  You  can  intro- 
duce, Reilly  says,  from  six  to  ten  ounces  in  one  place.  He 
says  no  accident  in  his  experience  has  followed  this  operation, 
not  even  cellulitis.  I,  myself,  have  seen  sloughing  in  a  run- 
down hospital  case,  so  be  careful  to  observe  the  proper  tech- 
nique. 

For  the  intravenous  method  Reilly  uses  a  glass  funnel  con- 
nected by  a  piece  of  rubber  tubing  three  feet  long  to  a  canula 
four  inches  long  by  one-eighth  of  an  inch  in  diameter, 
curved  at  its  point  one  inch,  to  better  introduce  it  into  the 
vein.  This  should  have  a  stop-cock.  Now  supine  the  fore- 
arm, cleanse  it,  bandage  it  tightly  at  its  middle  to  distend  the 
veins  at  the  elbow,  and  incise  one  inch  over  the  median  basilic 
or  cephalic  vein.  This  goes  through  skin  and  fascia ;  with  a 
grooved  director  tear  away  fat  and  tissues  over  the  vein  and 
raise  it;  pass  two  catgut  ligatures  under  the  vein;  now  tie 
the  distal  one,  or,  better,  wait  until  the  vein  has  been  opened. 
To  open  the  vein  make  a  clean  longitudinal  cut  three-eighths 
of  one  inch  long ;  now  introduce  the  canula  one-half  inch  up- 
ward; use  the  upper  ligature  to  tie  the  canula  in  place,  and 
take  off  the  bandage,  sure.  After  the  canula  is  removed  tie 
the  vein  with  the  ligature  and  close  wound. 

Dr.  Dawbarn  has  injected  the  fluid  into  a  large  artery  by 
an  aspiration  needle,  but  this  is  not  considered  safe.  There 
are  many  modifications  of  intravenous  methods,  hooking  up 
the  vein  in  any  way  you  are  able  and  using  even  a  medicine 
dropper,  and  I  do  not  see  why  any  vein  in  the  system  you  can 

'156 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

expose  will  not  answer.  There  is  little  or  no  clanger  of  air 
entering  to  cause  sudden  death;  this  is  now  well  proved.  It 
takes  about  five  minutes  for  one  (juart  of  s(jlution  to  run  in. 
The  quantity  to  be  used  is  from  a  few  ounces  to  several 
quarts.  Guides  to  quantity  are,  return  of  pulse  or  increase  of 
pulse,  return  of  color  and  consciousness,  etc.  Rarely  use  more 
than  one  quart  to  a  sitting,  but  it  can  be  frequently  repeated, 
and  the  canula  can  be  kept  in  place  for  this  purpose.  There  is 
little  danger  of  using  too  much  after  severe  hemorrhage. 
Watch  the  bladder,  as  it  may  distend  enormously.  Its  great 
use  is  in  loss  of  blood  from  various  causes.  Shock  is  another 
great  cause  for  its  use;  so  also  is  uraemia,  especially  in  ursemic 
convulsions.  Draw  ten  to  twelve  ounces  of  blood  from  the 
arm  and  introduce  a  quart  of  salt  solution,  and  in  a  few  hours 
you  can  give  if  necessary  as  much  more.  QEdema  of  lungs  is 
not  a  contraindication.  In  suppression  of  urine  it  may  be 
used.  In  diabetic  coma  it  may  save  life  in  this  almost  hopeless 
condition.  In  sepsis  of  all  kinds  it  is  doubtless  the  great  rem- 
edy. In  Asiatic  cholera  it  is  useful.  In  pneumonia  it  will 
save  life,  especially  in  double  pneumonia  with  dyspnoea,  etc. 
Use  it  here  as  soon  as  pulse  flags.  It  has  been  used  success- 
fully in  various  other  troubles,  including  purpura  hemor- 
rhagica, ulcerative  endocarditis,  pyelitis,  coal-gas  poisoning, 
mushroom  poisoning,  after  venesection,  after  extensive  burns, 
in  acute  alcoholism,  toxaemia  from  colon  bacillus,  painter's 
colic,  carbolic  acid  poisoning,  tetanus,  and  epilepsy. 

Reilly  thinks  it  will  do  great  good  in  arsenic  poisoning. 
He  speaks  of  it  going  into  the  blood  at  a  temperature  higher 
than  that  of  the  blood,  and  it  thus  increases  the  antitoxins  of 
the  blood  and  cures,  or  keeps  the  patient  up  until  the  crisis  has 
passed.  In  his  summar3\  Reilly  recommends  its  use  in  all 
cases  of  severe  hemorrhage,  external  or  internal ;  in  shock 
of  all  kinds  it  fulfils  all  indications.  In  all  toxaemic  condi- 
tions, bleed  first  and  then  use  it.  There  is  nothing  like  it  in 
uraemia  and  septic  conditions,  and  in  all  cases  of  vegetable  or 
mineral  poisonings.  In  any  pathologic  state  attended  with 
feeble  pulse  due  to  lessened  blood-pressure,  use  it,  and  as  a 

157 


FORTY   YEARS    IN    THE   MEDICAL   PROFESSION 

last  resort  in  all  cases  of  imminent  death  from  any  cause  of 
an  accidental  nature,  use  it. 

The  sheet  anchor  in  diagnosis  is  tact.  Do  not  jump  at  con- 
clusions too  rapidly.  The  special  diagnostician,  the  older  he 
grows,  becomes  more  non-committal,  and  leaves  a  loophole 
of  escape.  This  makes  him  no  less  a  diagnostician,  but  he  has 
learned  that  diagnosis  is  not  an  exact  science,  but  is  one  grow- 
ing and  expanding  every  day,  and  is  one  making  great  and 
rapid  strides  to  a  perfect  development,  and  one  that  requires 
all  the  strength,  all  the  force,  and  all  the  senses  of  a  man. 

Among  the  many  nice  points  in  diagnosis,  my  experience 
leads  me  to  refer  to  the  very  frequent  occurrence  of  movable 
kidney,  especially  in  women,  and  to  differentiate  this  from 
other  abdominal  lesions.  Dr.  Charles  P.  Noble,  surgeon-in- 
chief  of  the  Kensington  Hospital  for  Women,  at  Philadelphia, 
is  entitled  to  great  credit  for  original  work  in  this  lesion. 
Sometimes  small-pox  and  chicken-pox  may  cause  anxiety  for 
a  time  as  to  the  diagnosis,  and  people  are  liable  to  press  for  an 
immediate  opinion.  So  in  measles  in  the  negro,  as  to  the  pos- 
sibility of  its  being  of  the  variola  type.  Is  the  trouble  an 
aneurism,  a  tumor,  or  an  abscess?  My  experience  leads  me 
to  advise  great  care  in  any  trouble  where  the  lines  are  not 
definitely  marked  in  this  trio.  Drunkenness,  uraemia,  and 
apoplexy  are  another  trio  demanding  care,  knowledge,  good 
judgment,  and  tact;  and  opium  and  other  narcotic  poison- 
ings may  be  added  to  the  list,  and  also  malingering,  a  very 
common  failing  under  certain  conditions,  especially  among 
soldiers,  sailors,  prisoners,  paupers,  and  hospital  bummers. 

In  general  diagnosis,  do  not  forget  the  microscope,  and 
especially  do  not  forget  its  use  in  the  urine,  the  sputa,  and  the 
blood,  and  very  frequently  in  the  alvine  discharges.  When 
you  have  a  constant,  continued,  wearing  pain,  well  localized, 
study  it  thoroughly ;  examine  all  parts,  far  and  near,  possible 
to  be  involved,  and  especially  do  not  dismiss  it  as  a  form  of 
rheumatism  or  neuralgia.  It  is  probably  not  functional,  but 
of  organic  origin,  and  some  serious  formidable  trouble  is  apt 
to  show  itself  sooner  or  later.     An  aneurism,  a  malignant 

158 


FORTY    YEARS    IN    TJII':    MJ'DICAL    PROFESSION 

growth,  or  some  serious  lesion  of  the  nerve-centres  may  be- 
come the  sequel.  J3iagnosis  as  it  was  is  a  very  fascinating 
art.  I  say  art,  for  I  can  scarcely  call  it  a  science.  Diagnosis 
as  it  is,  is  still  a  fascinating  art,  but  true  science  is  just  begin- 
ning to  shed  its  indistinct  rays  of  light  on  it,  sufficient  to 
mystify  it  and  take  somewhat  from  its  fascination,  for  fascina- 
tion comes  from  mystery  and  from  conjecture  more  than  from 
demonstrated  fact. 

As  we  go  on  higher  up  the  mountain  to  the  goal  of  perfect 
knowledge,  we  are  giving  up,  must  give  up,  our  reasonings  by 
inductive  methods,  and  diagnosis  as  it  soon  will  be  commences 
to  unfold  itself  as  a  true  science.  Even  to-day  the  general 
practitioner  needs  continuous  recourse  to  bacteriology ;  he 
cannot  practise  medicine  and  be  just  to  himself  and  do  jus- 
tice to  his  patients  without  such  recourse.  A  diagnosis  cannot 
be  made  any  more  from  sight  alone,  from  touch  alone,  from 
hearing  alone,  from  the  sense  of  smell  alone,  or  from  the 
sense  of  taste  alone.  We  must  have  the  help  of  the  bacteriolo- 
gist, and  our  diagnosis  must  be  biologic  wherever  possible, 
not  mere  deductions,  not  mere  inductions.  In  the  future, 
diagnosis  is  to  be  a  true  and  progressive  science,  not  a  mere 
art,  and  in  making  this  advance  it  is  only  in  keeping  with 
other  great  advances  in  the  business  and  scientific  world. 

I  may  close  this  rather  desultory  talk  on  diagnosis,  and 
quote  two  practical  mistakes  which  I  know  were  made  many 
years  ago  by  practitioners  of  medicine,  and  which  go  to  show 
want  of  thoroughness,  want  of  tact,  and,  possibly,  want  of 
knowledge,  all  three  essentials  to  the  successful  physician. 
A  physician  was  called  to  see  a  young  unmarried  woman 
(and  these  are  the  cases  which  usually  throw  the  doctor  off 
his  guard)  on  a  hot  summer  night.  He  found  her  in  a  room 
surrounded  by  anxious  female  neighbors  and  her  own  mother. 
He  made  a  hurried  diagnosis  of  cholera  morbus,  and  pre- 
scribed a  mustard  plaster  and  a  narcotic  and  retired.  \Mien 
he  called  in  the  morning  he  was  met  at  the  door  by  an  old 
granny,  who  complimented  him  on  his  success,  and  showed 
him  a  bouncing  boy.    The  doctor  retired  without  in  any  way 

159 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

covering  his  retreat,  and  in  a  rather  short  time  left  the  town 
for  other  fields  of  conquest.  The  other  case  was  a  similar 
one,  except  that  the  doctor  had  tact,  got  out  of  the  scrape 
gracefully,  and  long  afterwards  the  family  never  knew,  when 
he  paid  his  second  visit  and  found  the  child  born,  that  on  his 
first  visit  he  had  left  without  an  idea  of  what  was  coming;  in 
other  words,  had  made  a  hasty  call,  a  hasty  diagnosis,  and  a 
humiliating  error.  To  the  diagnosis  of  pregnancy  in  any 
stage  the  greatest  embarrassment  is  apt  to  come  to  a  physi- 
cian, and  if  the  subject  be  a  young  unmarried  woman,  among 
the  very  greatest  of  all  embarrassments  confronts  him.  Here 
you  will  have  use  for  all  your  skill,  all  your  care,  and  all  your 
tact  and  knowledge.  In  these  unfortunate  cases  it  is  always 
prudent  to  call  a  medical  friend  in  consultation. 

As  not  altogether  out  of  place  here,  I  will  refer  to  a  peculiar 
condition  as  a  cause  of  disease  which  the  originator.  Dr.  E. 
Vallin,  calls  "  wall  disease."  He  speaks  of  the  presence  of 
saltpetre  in  the  walls  of  inhabited  houses.  On  the  brick  walls 
of  houses  in  Philadelphia,  Wilmington,  New  Castle,  and  sur- 
rounding towns  we  often  see  a  white  deposit,  especially  on 
the  chimneys.  This,  I  think,  has  been  demonstrated  to  be 
sulphate  of  magnesia,  and  comes  from  the  magnesia  in  the 
clay  from  which  the  bricks  have  been  made,  in  connection 
with  the  sulphur  compound  from  the  coal  burned  in  the 
houses.  Vallin  describes  this  trouble  as  a  disease  of  the  walls, 
due  to  the  presence  of  micro-organisms.  He  seeks  to  "  cure" 
the  walls,  as  he  puts  it,  to  save  those  living  in  the  houses. 
The  disease  is  caused  by  the  penetration  into  the  walls  of  the 
bacilli  of  nitrification,  and  consequently  the  houses  become 
damp  and  unwholesome.  This  is  likely  to  occur,  says  the 
London  Lancet,  the  account  of  which  I  take  from  the  Phila- 
delphia Medical  Journal,  in  damp  localities  and  in  the  pres- 
ence of  nitrogenous  organic  matter.  From  a  sanitary  point 
of  view  this  disease  of  the  walls  should  be  cured,  as  we  cure 
or  prevent  virulent  diseases  among  men  and  animals.  Vallin 
says,  first,  thoroughly  drain  the  ground  around  the  walls,  and 
isolate  them  from  the  surrounding  earth  by  a  trench  and  by 

i6o 


FORTY    YEARS    IN    'I'lllC    MICDICAF.    PROFESSION 

the  use  of  aspliall  cement  or  coal-tar.  Thus  the  access  oi 
water  heariuj^  nitrifying  hacteria  that  are  aerohic  vvfniUl  be 
prevented.  It  is  also  necessary  to  mix  the  mortar  used  with 
antiseptic  solutions,  such  as  dissolved  copper  sulphate,  etc. 
Where  these  precautions  had  not  been  taken,  and  the  disease 
had  already  broken  out,  then  he  advocated  the  ffjllowing 
treatment:  Mrst,  scrape  off  and  wash  awa\'  all  superficial 
traces  of  the  saltpetre  (and  magnesia,  too,  1  should  say,  if 
the  deposit  should  be  magnesia  and  not  potash).  Then  inocu- 
late the  walls  with  active  cultures  of  the  anti-nitrifying  bacilli, 
the  kind  which  impoverish  farm  manure  by  decomposing  the 
nitrates,  and  by  throwing  off  in  the  atmosphere  a  great  part  of 
the  nitrogen  which  they  contain.  These  walls  should  then  be 
covered  over  with  impermeable  paint,  so  as  to  retard  the  pro- 
cess of  nitrification  of  the  aerobic  germs,  and  on  the  other 
hand  to  stimulate  the  growth  of  the  anaerobic  and  anti-nitri- 
fying germs  which  remove  the  oxygen  from  the  nitrate,  and 
from  the  ammonia,  when  they  cannot  supply  themselves  with 
oxygen  from  the  atmosphere. 

This  ingenious  theory  has  made  quite  an  impression.  The 
idea  of  applying  the  principles  of  inoculation  to  the  preser- 
vation of  material  used  in  buildings  opens  a  vast  field  of  pos- 
sible progress  in  the  domains  of  sanitary  engineering  and 
architecture.  I  will  add  that  many  things  of  this  character 
are  being  done,  and  many  discoveries  have  been  and  are  being 
made  in  regard  to  the  nitrification  of  plants,  etc.  Take  the 
leguminous  plants.  It  is  now  known  that  they  are  provided 
by  nature  with  little  tubercles  on  their  roots,  nitrogen-traps, 
which  generate  little  micro-organisms  through  which,  or  bv 
the  aid  of  which,  or  both,  these  plants  receive  nitrogen  from 
the  atmosphere,  and  thus  store  it  up.  not  only  for  their  own 
use,  but  for  the  use  of  other  crops  to  follow  on  these  plants 
turned  under  the  soil.  Where  a  soil  becomes  sick  as  to  nitro- 
gen and  will  not  bear  the  legimiinous  plants,  it  is  a  custom 
now  to  supply  soil  from  a  field  not  thus  sick  and  where 
legimies  are  growing,  and  thus  revivify  the  sick  soil.  The 
German  chemists  are  now  supplying  bacteria  which  thev 
II  t6i 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

call  nitrigin  for  such  purposes,  and  this  may  become  a  com- 
mercial business.  Take  a  jar,  fill  it  with  earth,  thoroughly 
kill  all  organic  life  in  it,  and  sterilize  it  by  heat.  Plant  peas 
in  the  jar,  and  the  peas  will  not  grow.  Go  to  a  bed  in  the 
garden  where  peas  are  growing,  and  take  a  very  little  of  the 
earth  from  the  pea-bed  and  add  it  to  the  sterilized  earth,  and 
at  once  the  peas  start  off  and  grow.  Why?  Because  you 
bring  the  micro-organism  from  the  garden  soil  and  add  it  to 
the  sterilized  soil,  and  at  once  they  increase,  as  only  such 
organisms  can  increase,  and  we  have  the  essentials  for  the 
growth  of  the  peas  by  the  addition  of  this  microscopic  life. 
Just  as  we  add  a  little  yeast  to  the  bread,  and  the  prolifera- 
tion of  the  yeast-plant  acting  with  the  gluten  raises  the  bread. 
So  with  all  ferments  :  some  are  necessary  to  organic  life  under 
certain  conditions,  and  some  are  fatal  to  organic  life  under 
certain  conditions. 

All  of  this  is  of  the  utmost  importance  in  medicine.  When 
we  can  supply  to  the  human  organism  at  will  a  micro-organ- 
ism constructive,  as  it  were,  and  when  we  can  supply  to  the 
human  subject  at  will  a  micro-organism  destructive,  as  it 
were,  then  will  we  be  approaching  a  definiteness  and  an  exact- 
ness in  medical  science  which  will  raise  it  from  the  empiricism 
and  uncertainty  of  the  past,  and  make  the  physician  what  he 
is  rapidly  nearing,  one  who  can  get  definite  results  from  defi- 
nite means,  and  these  definite  means  being  in  great  measure 
the  application  of  nature's  laws.  It  being  undoubtedly  true 
that  every  organic  thing  in  nature  generates  its  own  organic 
poison,  which  really  means  limits  its  own  life,  the  converse 
may  be  true,  that  every  poison  thus  generated  by  an  organic 
body  may  prove  in  some  way  a  factor  in  making  life  possible 
in  other  organic  bodies. 

All  of  these  things  go  to  show  the  wonders  of  life,  and  how 
dependent  every  life  is  on  other  life,  until  we  come  to  man, 
who  holds  everything  in  the  organic  world  subservient  to  his 
own  existence  and  to  his  own  comfort,  and  how  this  whole 
scheme  of  life  is  beginning  to  dawn  on  him.  Whilst,  for 
instance,  he  has  always  held  the  ox  as  one  of  the  great  re- 

162 


FORTY    YEARS    JN    Till':    MICDICAL    I'ROl-ESSION 

sources  of  his  food  and  comf(jrt,  he  has  taken  Httle  account 
of  the  mere  microscopical  point,  a  Httic  thinj^  scarcely  defined 
as  to  its  place  in  nature,  whether  where  the  vegetable  ends  or 
the  animal  begins,  the  bacillus  of  diphtheria,  which  under 
favorable  circumstances  has  the  power  literally  to  drive  him 
from  the  earth.  He  is  just  beginning  to  sec  that  he  has 
power  also  over  this  little  unseen  enemy;  that  he  can  abso- 
lutely control  its  development  and  can  absolutely  render  its 
danger  to  himself  nil ;  and  this  history  of  this  little  germ 
shows  the  lines  upon  which  medicine  is  working,  and  gives 
an  insight  into  the  great  progress  now  dawning  on  the  medi- 
cal horizon. 

Now,  suppose  we  obtain  absolute  control  over  zymotic  dis- 
eases ;  suppose  we  absolutely  control  all  epidemics  heretofore 
so  fatal ;  we  have  confronting  us  great  questions  in  political 
economy.  The  Malthusian  theory  confronts  us, — that  popu- 
lation when  unchecked  by  wars,  vice,  epidemics,  and  other 
depopulating  causes,  increases  in  a  geometrical  ratio,  whilst 
food  can  only  be  made  to  increase  in  an  arithmetical  ratio. 
Well,  let  us  shut  our  eyes  to  all  coming  troubles  of  this  kind, 
knowing  full  well  that  the  future  will  take  care  of  itself,  and 
that  Providence  will  provide  a  way.  If  medicine  brings 
about  this  complicated  condition  by  putting  off  death  to  old 
age,  what  a  compliment  to  medicine  would  such  a  state  of 
affairs  be,  and  what  man  would  be  so  great  a  man  as  the 
doctor ! 

Serum  Therapy. — Among  the  recent  introductions  into 
medicine,  the  therapeutic  serums  have  been  the  most  remark- 
able and  promise  the  most  wonderful  results.  First  of  all, 
the  diphtheria  antitoxin  is  probably  best  known,  for  it  has 
undoubtedly  passed  the  experimental  stage,  and  none  of  our 
specific  remedies  to-day  are  probably  more  sure  than  is  the 
antitoxin  of  diphtheria  in  that  disease.  We  have  no  right 
now  to  treat  a  case  and  fail  to  give  its  use  due  consideration. 
There  is  no  doubt  but  that  the  illustrious  Washington  died  of 
diphtheria.  On  a  visit  to  Mount  Vernon,  when  I  was  ac- 
corded special  privileges  I  examined  the  house  and  premises 

163 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

thoroughly.  I  know  not  wh}'-,  but  in  the  good  old  times  the 
thrifty  housewife  seldom  allowed  the  best  quarters  to  herself 
or  her  family,  but  the  desirable  apartments  were  guest-cham- 
bers, which  were  often  full  owing  to  the  generous  hospitality 
of  the  day.  The  quarters  occupied  by  the  general  and  Mrs. 
Washington  were  the  smallest  and  meanest  of  the  establish- 
ment, very  near  the  kitchen  apartments  and  near  the  servants' 
quarters,  just  the  part  of  the  premises  furnishing  teeming 
hosts  for  all  pathogenic  germs,  and  a  home  and  surroundings 
just  as  acceptable  and  lovely  to  the  deadly  Klebs-Loeffler  ba- 
cillus as  it  was  to  the  great  man  and  his  wife, — at  once,  their 
home,  their  monument,  and  their  tomb. 

As  to  its  discovery,  manufacture,  etc.,  I  do  not  propose  to 
treat  of  them  here,  for  they  are  now  fully  described  in  all 
works  on  Materia  Medica.  When  it  first  came  out,  in  Eu- 
rope, I  sent  to  Germany  and  procured  a  quantity  from  Behr- 
ings',  and  before  I  had  had  possession  of  it  more  than  a  very 
few  days  I  was  called  in  consultation  by  Dr.  H.  G.  M.  Kol- 
loch,  of  Newark,  Delaware,  to  see  a  child  of  eighteen  months 
suffering  from  laryngeal  diphtheria  which  had  produced  ste- 
nosis and  serious  embarrassment  to  the  breathing.  We  used 
one  injection  of  about  seven  hundred  and  fifty  units.  In 
twenty-four  hours  there  was  marked  relief,  and  after  that 
prompt  recovery.  From  that  day  I  had  confidence  in  the 
diphtheria  antitoxin.  Those  now  made  in  this  country  by 
Mulford,  of  Philadelphia,  and  by  Parke  Davis  &  Co.,  of  De- 
troit, are  among  the  best,  and  the  price  is  getting  within  reach 
of  all.  I  have  never  seen  any  ill  effect  beyond  now  and  then 
a  rash,  which  soon  fades  away. 

The  true  secret  of  success,  in  my  experience,  is  to  use  it 
early  and  use  plenty  of  it.  Do  not  be  afraid  of  it.  Especially 
in  laryngeal  cases  use  large  doses.  I  have  seen  it  do  won- 
ders in  these  cases.  Before  its  introduction  I  lost  a  great 
many  of  these  cases,  notwithstanding  I  performed  a  number 
of  tracheotomies,  with  poor  success.  Although  many  in  the 
profession  held  out  a  long  time  against  what  we  called  true 
membranous  croup  being  true  diphtheria,  few  now  deny  it, 

164 


FORTY    YICARS    IN    TIIJC    MI':i)IC.\L    PROFESSION 

The  opponents  now  acknowledge  ninety-five  per  cent,  to  be 
genuine,  and  I  have  nr)  don1)t  but  that  the  r)thcr  five  per 
cent,  contain  the  l)acilhis. 

Some  years  ago,  when  this  matter  was  being  discussed 
warmly,  I  had  a  number  of  cases  in  which  1  had  made  trache- 
otomies which  bore  on  the  matter  and  confirmed  the  views  of 
Sir  Morell  Mackenzie  in  a  marked  degree.  I  prepared  some 
notes  of  the  cases,  and  sent  them  to  Sir  Morell,  and  I  had 
several  very  nice  letters  from  him  in  the  matter,  telling  me 
he  had  used  the  material  for  his  new  book  then  in  press,  and 
the  manuscript  of  which  was  destroyed  by  fire  while  in  the 
printer's  hands.  I  never  give  less  than  five  hundred  units  to 
an  infant  under  twelve  months,  and  repeat  it  as  often  as  neces- 
sary. Children  require  larger  proportionate  doses  than  adults, 
for  they  are  more  susceptible  to  the  disease  and  carry  more  of 
the  toxine.  In  laryngeal  cases  over  two  years  of  age.  never 
start  with  less  than  two  thousand  units,  and  do  not  hesitate 
to  repeat  in  eight  to  twelve  hours,  and  re-repeat  as  necessary. 
These  are  the  cases  to  be  bold  in,  and  are  the  cases  which 
give  us  the  Avonderful  results  and  are  making  tracheotomy 
and  even  intubation  less  and  less  necessary.  I  think  it  best 
to  immunize  all  the  children  in  the  family  if  there  is  a  case  in 
the  house,  and  do  not  use  less  than  five  hundred  units,  as  a 
rule,  for  immunization.  Begin  as  soon  as  you  detect  the  case, 
and  do  not  wait  for  microscopic  confirmation.  If  the  case 
goes  on  over  thirty-six  hours,  you  begin  to  have  streptococcus 
toxine  poison. 

I  have  not  used  the  combined  treatment  of  diphtheria  anti- 
toxin and  streptococcus  antitoxin,  but  such  is  recommended. 
Do  not  let  your  case  go  on  to  secondary  infection.  As  to  local 
treatment,  do  all  you  can  with  it.  One  to  two  per  cent,  solu- 
tion of  formaldehyde  will  do  wonders  in  most  cases.  This 
local  treatment  is  all  very  well  in  adults  and  in  children  old 
enough  to  be  reasoned  with.  In  children  where  you  have  to 
fight  them  and  exhaust  them  by  your  eflforts  to  use  local  treat- 
ment, drop  it  when  you  come  to  this  point.  I  am  sure  they 
lose  more  than  they  gain  by  their  efforts  at  resistance  and  by 

i6= 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

fright.  ,  All  the  tact  and  all  the  skill  of  a  good  nurse  will  not 
overcome  these  troubles  in  many  children.  Food  and  nour- 
ishment and  absolute  recumbent  rest  are  most  important,  and 
where  necessary  tracheotomy  and  intubation  are  to  be  enter- 
tained. Watch  the  heart  for  weakening,  particularly,  and 
keep  in  mind  digitalis,  trinitrin,  strychnine,  atropine,  and 
alcohol.  Champagne  is  the  best  stimulant,  or  heavy  wines 
in  carbonated  waters.  If  your  patient  be  a  negro  you  will 
usually  find  the  disease  of  virulent  type. 

Another  point :  the  antitoxin  as  now  furnished  comes  much 
more  potent  as  to  quantity  than  formerly.  Mulford  puts  up 
five  hundred  units  to  one  cubic  centimetre.  At  this  rate  it  is 
easily  used  in  a  first-class  hypodermic  syringe,  and  there  is 
no  necessity  for  the  large  quantity  of  fluid  and  the  large  cum- 
bersome syringe  which  first  came  out.  Of  course,  in  its  use, 
observe  on  every  hand  the  most  perfect  antiseptic  precau- 
tions. In  tuberculous  troubles,  I  believe  I  have  used  almost 
all  the  serums  that  have  come  out  and  one  or  two  of  my  own 
ideas,  but  have  no  real  success  to  report,  and  will  refer  to  this 
matter  again,  when  I  come  to  speak  of  tuberculosis  in  gen- 
eral. 

In  tetanus  I  have  had  experience  only  with  one  case, — a 
boy  of  fifteen,  who  had  wounded  his  foot  with  a  rusty  nail 
some  days  before,  and  who  had  marked  premonitory  symp- 
toms of  tetanus  when  I  saw  him.  In  twelve  hours  I  saw 
him  again  (having  treated  the  wound  medicinally  before  I 
left  him),  and  during  my  absence  he  had  taken  chloral  and 
potassium  bromide  in  full  doses.  Having  obtained  the  anti- 
toxin of  tetanus  from  Dr.  Gibier,  of  the  Pasteur  Institute, 
New  York  City,  I  used  it  according  to  directions.  The  boy 
was  really  better  when  I  commenced  the  use  of  the  antitoxin, 
but  still  had  marked  symptoms.  He  gradually  improved  and 
got  well. 

An  editorial  in  the  University  Medical  Magazine,  February, 
1899,  gives  a  good  synopsis  of  the  treatment  of  tetanus  to  date 
by  serum.  Wasserman,  it  says,  showed  that  a  mixture  of  teta- 
nus toxine  with  the  brain  or  spinal  cord  of  a  susceptible  ani- 

166 


FORTY    YIOARS    IN    Till-:    Mi":iJlC,\l.    PROFESSION 

mal  could  l^e  injected  into  a  guinca-pij(  siibctitaneously  with- 
out causing  tetanus,  while  the  same  quantity  of  toxine  without 
the  admixture  of  brain  or  cord,  invariably  caused  fatal  teta- 
nus. This  gave  Roux  and  Borrel  a  pointer,  and  they  treated 
forty-five  guinea-pigs  in  which  tetanus  had  been  produced 
artificially  by  injecting  tetanus  antitoxin  into  the  brain,  thirty- 
five  of  which  recovered.  Of  seventeen  treated  by  subcuta- 
neous injections  of  antitoxin,  in  much  larger  doses  than  was 
thrown  into  the  brains  of  the  forty-five  cases,  only  two  re- 
covered. Of  seventeen  animals  tetanized  and  allowed  to  go 
without  treatment,  all  died. 

It  is  a  serious  matter  to  throw  anything  into  the  brain,  but 
these  are  serious  cases.  Use  two  and  one-half  centimetres 
of  double  strength  tetanus  antitoxin  serum.  Do  everything 
antiseptically.  Trephine  with  a  small  trephine  or  Archime- 
dean drill.  The  spot  to  choose  is  two  and  one-half  inches 
above  the  external  angular  process  of  the  orbit  and  one  and 
three-quarters  inches  from  the  median  line.  Introduce  the 
needle  two  inches  into  the  frontal  lobe,  and  inject  drop  by 
drop,  allowing  ten  minutes  for  the  injection.  At  the  same 
time  inject  twenty  cubic  centimetres  of  ordinary  tetanus  anti- 
toxin subcutaneously. 

Heckel  and  Reynes  thus  group  tetanus :  Where  incubation 
is  fourteen  days  or  more,  temperature  below  39°  C,  and  a 
little  dyspnoea,  here  serum  treatment  will  cure.  In  subacute 
cases  running  a  rapid  course,  with  dyspnoea  and  irregular 
pulse,  intracerebral  injections  may  cure  if  used  promptly.  In 
acute  cases  beginning  in  from  five  to  seven  days,  temperature 
over  40°  C,  with  rapid  appearance  of  spasm,  oleguria,  rapid 
breathing,  and  rapid  pulse,  use  serum  therapy  subcutaneously 
as  soon  as  trimsus  appears.  Puerperal  tetanus,  tetanus  ne- 
onatorum, and  the  cephalic  tetanus  of  Rose  are  not  favorable 
cases  for  serum  treatment.  The  first  essential  of  treatment 
is  early  diagnosis.  When  trismus  appears,  the  disease  has 
passed  far  along.  It  then  becomes  a  question  of  intracerebral 
injection  of  antitoxin.  Our  great  eft'ort  should  be  to  find 
something  to  make  out  the  form  before  trismus  appears. 

167 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

The  bacillus  of  tetanus,  in  my  experience,  is  common  in 
low  countries  and  in  marshy  places,  and  is  especially  common 
about  horse-stables  and  on  farms  on  river-sides.  It  is  an 
aerobic,  and  hides  in  the  dark.  The  bacilli  and  not  the  toxine 
is  usually  the  matter  inoculated,  and  it  takes  some  days  for 
the  toxine  to  form  in  the  system  as  a  result  of  the  bacilli  inoc- 
ulation. One  thing  remember :  the  bacilli  of  tetanus  have 
probably  more  tenacity  of  life  than  all  other  of  the  disease- 
producing  germs,  and  the  tetanus  toxine  is  the  most  virulent 
of  toxines.  Bichloride  of  mercury  solution  one  to  one  thou- 
sand will  not  destroy  them  in  an  hour  or  more.  They  will 
stand  more  boiling  than  all  other  of  the  disease  germs.  Be  on 
your  guard;  remember  this  as  a  practical  point  in  surgical 
operations  and  in  treating  the  local  wounds  in  cases  of  trau- 
matic tetanus  (indeed,  even  trivial  wounds)  :  boil  all  water 
used  at  least  one  hour,  if  it  comes  from  a  source  suspicious 
as  to  tetanus  bacilli,  or  you  may  have  tetanus  following  your 
operation,  and  wonder  where  it  came  from.  Tetanus  has  also 
been  treated  by  carbolic  acid,  known  as  Baccelli's  method. 
A  two  per  cent,  solution  is  used  hypodermically,  at  intervals 
of  two  to  three  hours,  using  three  grains  a  day,  rapidly  in- 
creasing to  six  to  eight  grains  a  day.  The  system  is  very 
tolerant  of  carbolic  acid  in  tetanus.  This  is  claimed  to  give 
better  results  than  the  antitoxin  treatment.  Dr.  D.  F.  Woods, 
of  Philadelphia,  has  reported  a  very  interesting  case  cured 
by  the  carbolic  acid  treatment. 

I  have  had  little  experience  with  transfusion  and  infusion, 
but  will  mention  it  later  on,  in  Chapter  IX.  Lentz  &  Sons 
have  a  very  efficient  apparatus  for  the  latter  work.  My  expe- 
rience leads  me  to  advise  great  care  in  injecting  fluids  into 
the  cellular  tissues  in  large  amounts,  as,  in  such  a  case,  where 
the  patient  was  weak  and  run  down,  I  have  seen  very  trouble- 
some sloughing  follow.  The  normal  saline  solution  is  a  sim- 
ple one :  add  one  teaspoonful  of  common  salt  to  one  pint  of 
water  previously  boiled  one-half  hour ;  boil  this  ten  minutes, 
strain  it  thoroughh^,  and  inject  it  at  a  temperature  of  about 
1 00°   F.     Where  we  have  oedema  of  the  lungs, — a  patient 

168 


FOin'Y    YI'lAkS    IN    'I'll  I'.    MIJJICAL    i'KOI-'ICSSION 

drowiiinj;',  as  it  were,  in  his  own  lluids, — be  careful  of  jabo- 
randi  and  pilocarpine;  sudden  dcitli  may  follow  from  any 
but  its  very  careful  use.  Hot  baths  and  sweats  are  safer. 
Here  intravenous  saline  injections  may  come  in,  especially 
where  there  is  uraemia,  say  a  (|uart  into  the  most  convenient 
veins;  hut  be  very  guarded  at  every  point  in  this  work.  In- 
traperitoneal injection  in  these  cases  really  might  be  the  safer, 
and  either  may  be  used  after  shock  from  extensive  burns. 

Much  has  been  said  and  written  about  the  imcleins  and 
the  nuclein  preparations,  and  great  disappointment  so  far  in 
my  experience  has  followed  their  quite  extensive  use.  In 
one  well-marked  case  of  expanding  sarcoma  of  the  femur  a 
free  use  of  proto-nuclein,  both  hypodermically  and  by  the 
mouth,  did  really  appear  to  retard  the  advance  of  the  lesion. 
but  then  we  all  know  such  cases  often  remain  dormant  for  a 
time  after  rapid  growth,  and  then  after  a  time  advance  again 
and  go  on  to  death,  as  did  the  case  I  am  speaking  of.  In 
lympho-sarcoma,  after  faithful  trial,  I  have  never  seen  the 
nucleins  or  any  other  treatment  retard  the  growths,  and  I 
have  had  the  same  experience  after  trials  of  the  bacillus  pro- 
digiosus  and  erysipelas  toxine  in  malignant  disease.  I  have 
never  had  the  opportunity  of  trying  the  method,  but  it  has 
been  recommended  to  me  from  a  source  worthy  of  regard,  in 
the  case  of  a  hsemophilic  bleeding,  to  apply  blood  from  a 
healthy  person,  and  thus  check  the  hemorrhage. 

Whilst  on  this  subject,  let  me  refer  to  the  effect  of  the 
sting  of  the  honey-bee  on  human  beings.  I  ha\'e  made  some 
practical  study  of  this  subject,  and  am  prepared  to  affirm  that 
from  frequent  stings  the  individual  becomes  immune  to  the 
poison,  in  many  cases  absolutely  immune,  and  this  stud}-  of 
the  efifect  of  bee-stings  has  impressed  me  forcibly  as  to  the 
possibility  of  rendering  man  and  other  animals  immune  to  all 
organic  poisons  of  creature  origin  or  vegetable  origin,  whether 
pathogenic  or  otherwise.  I  know  of  one  bee-keeper,  with  a 
wife  and  several  children,  who  are  all  more  or  less  immune 
to  the  poison  of  the  sting.  In  all  of  them,  immunity  has  come 
by  degrees,  after  frequent  stings.     The  man  assures  me  he 

169 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

can  now  be  stung  two  hundred  times  in  twenty-four  hours 
and  feel  no  ill  effects,  locally  or  constitutionally.  From  his 
first  stings  he  suffered  acutely.  He  is  always  careful  to  brush 
off  the  stings  so  they  wall  not  be  held  by  the  little  saw-like 
teeth  at  the  end.  The  poison  is  a  transparent  fluid  of  sweetish 
taste  and  acid  reaction,  and  the  antidotes  are  potassium  per- 
manganate and  ammonia  or  other  alkalies.  The  queens  and 
workers  have  the  stings,  whilst  the  males  have  none.  When 
it  is  known  that  very  numerous  stings  have  killed  horses,  and 
would  probably  kill  a  man,  the  fluid  compares  in  virulence 
with  many  of  the  serpent  poisons  when  we  consider  the  com- 
parative amounts  involved  in  bee-stings  and  serpent-bites,  and 
these  comparative  studies  become  most  interesting  and  useful. 
I  have  never  met  any  one  naturally  absolutely  immune  to 
the  sting  of  the  honey-bee,  but  have  seen  such  cases  reported. 
I  have  never  met  a  bee-keeper  who  was  not  more  or  less  im- 
mune after  frequent  exposures,  but  I  have  heard  of  some  few 
cases  where  no  tolerance  ever  became  established.  The  possi- 
bility of  causing  immunity  in  the  individual  to  such  troubles 
as  the  bites  of  serpents  and  such  creatures  by  the  use  of  the 
poison  of  the  sting  of  wasps,  bees,  and  such,  is  beginning  to 
attract  attention,  and  my  friend,  who  can  endure  two  hundred 
honey-bee  stings  in  twenty-four  hours,  may  have,  from  the 
toxines  of  these  stings,  sufficient  antidotal  and  antitoxic  prop- 
erties developed  in  his  system  to  withstand  the  bite  of  the 
rattler,  or  even  of  the  cobra.  Who  knows?  Who  wall  make 
the  trial?  No  one  willingly,  probably,  but  some  poor  jungle- 
dw^eller  ma}^  yet  be  the  subject  to  demonstrate  the  fact.  There 
is  another  interesting  question  as  to  the  honey-bee,  and  maybe 
to  other  stinging  insects  so  far  as  I  know.  I  refer  to  the 
action  of  its  sting  poison  on  the  poison  of  rheumatism  in  man. 
It  has  been  quite  well  established,  as  we  know,  that  rheuma- 
tism has  its  pathogenic  germ,  and  hence  we  may  infer  that 
this  has  its  antitoxin  either  in  nature  or  artificially  produced. 
As  before  stated,  the  poison  of  the  bee  is  a  clear  fluid,  with  a 
sweetish  acid  taste,  with  an  acid  reaction,  the  acid  being  prob- 
ably formic  acid.     Organic  toxines  usually  lose  their  viru- 

170 


FORTY    YEARS    IN    THIC    MEDICAL    PROFESSION 

lence  in  the  presence  of  an  (jr^anic  acid.  Possibly  here  may 
be  the  secret.  Be  it  as  it  may,  from  my  talks  with  experi- 
enced bee-keepers  and  bee  experts,  and  from  my  own  experi- 
ments with  the  action  of  the  bee-sting  upon  human  beings 
suffering  from  rheumatism,  I  am  satisfied  there  is  some  an- 
tagonism between  the  bee-poison  and  the  toxine  of  rheuma- 
tism, and  that  not  only  does  the  bee-poison  neutralize  in  a 
measure  the  rheumatism  toxine,  but  it  also  for  a  time  at  least 
renders  the  system  immune  to  a  greater  or  less  extent  to  said 
poison.  I  look  upon  the  matter  as  worthy  of  fuller  investiga- 
tion both  as  to  rheumatism  and  to  gout. 

I  gather  from  the  report  of  the  Secretary  of  Agriculture 
and  from  an  article  in  the  Philadelphia  Medical  Journal  on 
"  Diseases  and  Abuses  of  Animals  in  the  United  States,"  by 
Dr.  D.  E.  Salmon,  the  accomplished  head  of  the  National 
Bureau  of  Animal  Industry,  most  encouraging  statements  of 
the  serum  treatments  in  the  diseases  of  the  lower  animals ; 
and  these  statements  go  far  to  confirm  and  strengthen  all  such 
treatments  in  man  now  in  their  very  infancy,  but  which  soon, 
mark  my  words,  are  destined  to  give  to  the  results,  when 
compared  with  all  that  has  heretofore  been  done  in  the  science 
of  medicine,  a  brilliancy  and  success  the  most  sanguine  among 
us  have  little  dreamed  of.  The  matters  referred  to,  among 
others,  are  swine  plague  and  hog  cholera.  In  the  Bureau  of 
Animal  Industry  they  have  demonstrated  these  as  distinct  in- 
fectious diseases.  They  have  shown,  having  found  the  germs 
of  each,  ho\v  they  leave  the  bodies  of  sick  animals,  and  are 
disseminated,  and  how  they  get  into  the  bodies  of  healthy 
animals  and  make  them  sick.  They  have  experimented  with 
medicines  and  disinfectants;  they  have  tested  the  method  of 
killing  all  diseased  animals  and  burning  them.  They  have 
tested  vaccination,  inoculation,  and  serum  treatment.  Salmon 
says  the  practicable  and  efficient  plan  has  been  found  in  the 
serum  treatment. 

Ten  millions  of  hogs  die  annually  of  these  infectious  dis- 
eases. Think  of  such  a  terrible  slaughter  by  disease,  and  how 
easily  such  a  holocaust  might  fall  on  man !    Such  might  easily 

171 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

be  the  case ;  the  material  is  all  about  us  in  nature  for  just  such 
plagues,  and  to  think  that  by  science  everything  points  to  the 
fact  that  man  can  control  such  an  outbreak,  whether  in  man 
or  in  the  lower  animals.  Think  how  Pasteur  pointed  the  way, 
and  how  his  great  helpers  are  day  by  day  working  to  the  per- 
fect end.  In  these  hog  epidemics — or  rather  epizootics — the 
serum  treatment,  used  in  herds  where  seventy-five  per  cent,  of 
them  were  too  sick  to  eat,  caused  many  in  twenty-four  hours 
to  eat,  and  on  the  third  day  a  great  part  of  the  herd  would  be 
wonderfully  improved.  In  herds  treated,  seventy-eight  per 
cent,  were  saved.  In  untreated  herds,  fifteen  per  cent,  only 
recovered.  In  a  few  days,  in  treated  herds,  the  disease  is 
stopped.  All  this  means  the  saving  of  ten  millions  of  hogs  a 
year.  How  many  animals,  how  many  human  beings,  does  it 
mean  annually  saved,  and  what  an  improvement  in  the  eco- 
nomics of  animal  industry  when  these  true  scientific  princi- 
ples are  successfully  applied,  as  they  surely  zvill  be,  to  all 
zymotic  diseases,  to  all  diseases  caused  by  pathogenic  germs, 
not  speaking  of  the  possibility  of  immunizing  both  man  and 
the  lower  animals  to  all  such  germs,  as  Jenner  did  in  his  small 
way  many  years  ago !  How  can  we  help  but  become  enthu- 
siastic as  science  unfolds  her  mysteries ! 


172 


CH  A  PT  IC  k    VII. 

Nervous  Diseases  Forty  Years  Ago — Soninamlnilisni — Hypnotism — 
Motor  Disorders — Lunacy — Delirium  Tremens — Kpilepsy — Chorea — 
Diseases  of  the  Cord  and  its  Membranes — Tetanus — Hydrophobia — 
Hysteria — Neurasthenia — Dr.  D.  D.  Richard,son's  Views  on  the  Treat- 
ment and  the  Care  of  the  Insane — The  Fceble-Minded — Notes  by  Dr. 
Martin  W.  Barr — The  Deaf  and  Dumb — Colonel  William  Boiling — 
John  Brainwood — Thomas  Hopkins  Gallaudet — Edward  Miner  Gallau- 
det  —  Hon.  Amos  Kendall  —  Dr.  Crouter  —  Peet  —  Rogers  —  (iilletl — 
Noye.s — Fay — Manual  Method  and  Speech — Swedish  Movements — The 
Bath — Electricity — The  Masseur  and  the  Masseuse — Hypnotic  Sugges- 
tion— The  Dangerous  Classes — The  Degenerates — How  shall  the  Prob- 
lem be  solved? 

Forty  years  ago  the  nervous  system  and  its  diseases,  com- 
pared with  the  present  time,  were  little  understood,  and  it  was 
a  great  field  in  medicine,  little  worked  and  less  tilled.  Take 
the  classification  of  nervous  diseases  in  a  popular  work  on  the 
practice  of  medicine  at  that  period,  and  it  ran  perhaps  in  this 
fashion :  Diseases  of  the  brain,  under  which  we  would  get 
inflammation  of  the  brain  and  its  membranes,  acute  and 
chronic,  cerebritis,  tuberculous  troubles ;  organic  diseases  of 
the  brain;  softening,  hypertrophy,  tumor,  apoplexy;  func- 
tional diseases  of  the  brain ;  nervous  irritation,  vascular  irri- 
tation, depression ;  then  morbid  phenomena,  as  headache, 
stupor,  sunstroke ;  then  came  mental  disorders,  ecstasy,  som- 
nambulism, artificial  somnambulism  or  animal  magnetism,  or 
mesmerism,  now  called  hypnotism ;  then  came  motor  disor- 
ders, convulsions,  catalepsy.  The  next  division  is  lunacy,  and 
under  it  the  different  divisions  of  the  day,  as  monomania, 
insane  impulse,  etc. ;  then  comes  delirium  tremens,  and  what 
student  in  the  days  of  Professor  George  B.  Wood  and  William 
Pepper,  Sr.,  does  not  remember  the  horrible  imaginings  dis- 
played on  canvas  by  a  recovered  patient  as  among  the  recol- 
lections of  his  visions  and  dreams  during  his  illness.     At  the 

^73, 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

close  of  the  lecture,  with  what  form  and  ceremony  and  much 
ado  did  Levick  remove  the  cover  and  expose  them  to  the  ex- 
pectant gaze  of  an  applauding  audience.  Then  came  epilepsy 
and  chorea,  then  diseases  of  the  cord  and  its  membranes,  and 
then  functional  diseases  of  the  same,  as  tetanus — so  it  was 
placed  in  those  days — and  hydrophobia;  then  inflammation 
of  the  nerves,  under  which  came,  chiefly,  neuralgia;  then  a 
sub-section,  paralysis,  and  lastly  hysteria.  Such  was  about 
George  B.  Wood's  classification. 

The  causes  of  the  troubles,  the  pathological  conditions, 
were,  comparatively  with  the  present  day,  little  understood, 
and  the  treatment  was  on  the  general  principles  then  in  vogue. 
Read  su'ch  descriptions  to-day, — and  they  were  good  descrip- 
tions, too,  for  their  time, — and  then  compare  them  with  ner- 
vous diseases  in  a  standard  work  on  practice  at  the  present 
time;  or,  better  still,  with  the  grand  work  of  Mills,  just  out, 
or  even  with  Rosenthal's  work  of  twenty  years  ago,  and  we 
see  at  once  what  a  great  branch  of  medicine  has  arisen  based 
on  the  nervous  system  and  its  diseases,  and  what  great  work 
has  been  done  by  such  men  as  Charcot,  Rosenthal,  Weir 
Mitchell,  Sinkler,  Mills,  Dercum,  Taylor,  Dana,  Horatio 
Wood,  Seguin,  and  other  equally  able  and  zealous  men.  A 
grand  system  has  been  built  up  from  a  beginning  so  small  as 
to  be  almost  insignificant,  and  in  proof  of  this  it  is  only  neces- 
sary to  refer  to  the  great  improvements  in  classification,  in 
our  knowledge  of  the  causes  of  nervous  troubles,  of  their 
pathology,  and  of  their  treatment. 

I  may  mention  the  knowledge  we  have  gained  of  the  local- 
ization of  cerebral  functions  as  a  great  step  in  advance  in 
general  medicine  and  surgery.  The  knowledge  we  have 
gained  of  neurasthenia,  the  American  disease,  so  called,  is 
another  great  advance  and  practical  help  in  every-day  prac- 
tice. 

It  is  not  my  purpose  here,  nor  does  it  come  within  the 
scope  of  this  work,  to  go  into  details  of  any  kind  in  ref- 
erence to  nervous  diseases,  but  I  propose,  in  showing  the 
contrast  between  the  past  and  the  present,  to  give  in  detail 

174 


FORTY    YEARS    IN    THE    MEDICAE    PROFESSION 

statements  made  to  me  showing  such  contrasts  by  three  oi  the 
<'il)lest  men  we  have  in  the  profession  in  their  several  special- 
ties to-day.  T  will  refer  first  to  matters  pertaining  to  the  in- 
sane. Dr.  1).  D.  Richardson,  the  well-known  alienist  and 
superintendent  of  the  State  Hospital  at  Norristown,  Penn- 
sylvania, has  kindly  given  me  the  following  answers  to  my 
inquiries  connected  with  his  specialty  :  "  The  changes  in  the 
treatment  of  the  insane  for  the  past  thirty-eight  years  has 
consisted  in  the  amplification  of  the  methods  dating  back  to 
1844.  Physicians  have  arrived  at  the  unanimous  conclusion 
that  insanity  comes  of  disease.  The  courts  do  not  stand 
wholly  on  this  solid  foundation,  though  I  am  glad  to  say 
there  are  many  of  the  learned  bench  who  hold  with  us  that 
insanity  is  the  outcome  of  sick  physiology  or  pathology.  Hip- 
pocrates taught  that  insanity  is  caused  by  disease.  The 
mythical  notion  that  the  insane  were  possessed  of  the  devil 
was  not  countenanced  by  this  most  celebrated  physician  of 
ancient  times.  Gymnastic  and  calisthenic  exercise  holds  a 
foremost  place  in  the  physical  culture  of  the  insane.  Herodi- 
cus,  an  ancient  physician  of  Thrace,  and  one  of  the  medical 
educators  of  Hippocrates,  insisted  upon  the  application  of 
gymnastics  in  the  prevention  and  treatment  of  disease,  and 
the  spark  has  been  caught  up  and  kindled  the  enthusiasm  of 
alienists  to  such  an  extent  that  there  is  hardly  a  hospital  of 
any  pretensions  where  physical  culture  is  not  advocated  and 
promulgated.  The  ramifications  have  led  to  the  dance,  the 
bowling-alley,  the  billiard-table,  foot-ball,  base-ball,  racing, 
and  jumping.  Then,  too,  it  has  extended  its  usefulness  to 
horticulture  and  to  agriculture.  Fifty  per  cent,  of  the  cures 
at  the  Norristown  Hospital  may  be  attributed,  I  think,  to 
exercise  in-doors  and  out-of-doors.  From  1839,  when  Con- 
nolly began  the  non-restraint  system,  to  the  present  time 
alienists  have  favored  less  and  less  all  forms  of  restraint. 
Some  hospitals  claim  to  have  entirely  discarded  it,  others  to 
have  modified  it  to  the  minimum.  Very  much  pro  and  con 
may  be  said  upon  this  important  subject.  My  own  practice 
has  been  to  avoid  it  if  the  best  interest  of  the  patient  justified 

175 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

it.  It  is  due  to  Connolly's  love  of  his  fellow-man  to  say  that 
his  noble  efforts  have  borne  good  fruit.  Blood-letting  in  the 
treatment  of  the  insane  has  seen  its  day.  It  was  practised  too 
frequently  in  early  times,  and  now,  though  seldom  used,  is 
used  quite  often  enough.  The  supporting  plan,  feeding  often 
and  to  repletion,  meets  with  better  and  more  satisfactory 
results.  Purgatives  do  not  constitute  an  essential  part  of  the 
treatment  of  the  insane,  but  it  is  believed  to  be  indispensable 
that  the  contents  of  the  alimentary  canal  should  be  evacuated 
daily.  This  treatment  has  gained  favor  in  hospitals,  and 
nurses  are  especially  instructed  as  to  the  evils  of  constipation 
and  the  necessity  of  instructing  their  patients  as  to  the  pro- 
priety of  after-breakfast  visits  to  the  water-closet.  Opium 
and  its  constituents  are  used  less  frequently  than  formerly. 
Chloral,  introduced  in  1871  and  freely  administered,  is  used 
with  more  caution  now.  Hyoscine  is  a  reliable  remedy,  and  is 
to  be  recommended,  its  tastelessness  facilitating  its  adminis- 
tration. Paraldehyde  acts  well  in  many  instances.  Sulpho- 
nal  is  a  safe  remedy,  producing  sleep  quite  like  '  nature's  sweet 
restorer.'  Trional  is  looked  upon  with  favor  by  many  physi- 
cians. All  of  these  remedies  are  regarded  with  suspicion  by 
some  of  the  profession,  and  are  substituted  by  feeding  night 
as  well  as  day.  The  therapeutics  of  insanity  have  come  to  be 
more  like  the  therapy  of  other  diseases.  Physicians  know 
now  that  there  is  no  specific  remedy  for  this  '  ill  that  flesh  is 
heir  to,'  and  that  the  physical  condition  should  receive  our 
first  attention.  We  have  learned  to  regard  physical  improve- 
ment as  the  sine  qua  non  which  brings,  sooner  or  later,  the 
dawn  of  '  the  perfect  day'  of  mental  restoration.  Occupation, 
diversion,  encouragement, — these  three  words  are  more  deeply 
engraven  upon  the  minds  of  the  superintendents  of  the  pres- 
ent day.  Of  recent  years  considerable  attention  has  been 
given  to  electricity  and  massage,  in  the  hope  that  muscular 
tone  might  be  developed.  This  practice,  supplemented  with 
nutritious,  assimilable  food,  open-air  exercise,  followed  by 
several  hours'  rest  in  bed,  has  made  good  showing,  and  bids 
fair  to  continue  to  bring  favorable  results.    The  thermometer 

176 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

is  in  general  and  more  satisfactory  use.  y\nalysis  of  the 
urine  and  blood  are  more  and  more  engaging  the  attention  of 
ahenists.  Thorough  physical  examinations  on  admission  are 
mucli  more  thoroughly  prosecuted.  Entertainments  are  fre- 
quent and  diversified.  Schools  for  training  attendants  have 
been  organized  in  many  of  the  hospitals,  and  thus  a  more 
intelligent  and  competent  class  of  nurses  is  secured,  and  the 
outlook  becomes  more  favorable  as  we  work  on  hoping  and 
trusting." 

What  Dr.  Richardson  has  thus  hastily  written  is  sufficient 
to  show  the  advances  made  and  being  made  in  the  treatment 
of  those  who  have  lost  the  use  of  their  reason,  and  chains  and 
bolts  and  bars  are  not  even  alluded  to,  so  thoroughly  have 
they  gone  out  and  their  places  been  taken  by  custodial  care, 
the  patient  being  always  or  nearly  always  under  intelligent 
observation.  The  feeble-minded  are  an  interesting  class  to 
the  physician,  indeed  to  all  intelligent  people,  and  when  we 
compare  the  condition  of  those  gathered  in  our  thoroughly 
supervised  institutions  devoted  to  the  care  of  such  unfortu- 
nates with  the  poor  imbeciles  we  encounter  in  private  homes 
and  those  we  see  daily  on  the  streets  of  our  cities  and  towns, 
or,  more  unfortunate  still,  those  who  shamble  along  the  vil- 
lage walks,  the  butt  of  the  boys,  loved  by  few  and  respected 
by  none,  it  is  then  and  only  then  we  see  the  grand  work  such 
schools  are  doing,  and  at  once  we  stand  in  awe  and  admira- 
tion at  the  self-sacrifice  of  their  teachers  and  of  those  un- 
selfish men  and  women  who  have  given  time  and  money  with- 
out stint  to  help  these  poor  and  weary  ''children  of  a  day," 

Dr.  Martin  W.  Barr,  the  distinguished  physician-in-chief 
of  the  Pennsylvania  Training  School  at  Elwyn,  and  the  suc- 
cessor of  the  lamented  Dr.  Kerlin,  one  of  the  great  pioneers 
in  the  work,  has  kindly  given  me  a  few  notes  in  reference  to 
these  people,  and  I  take  great  pleasure  in  giving  them  at 
length,  with  the  assurance  that  they  will  prove  most  inter- 
esting. 

"  The  imbecile  is  traced  through  all  the  ages,  all  climes. 
We  find  him  as  the  Fatura  of  Rome,  the  Tardivi  of  Italy,  Les 
12  177 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Enfants  Arrieres  of  France,  Geistig  Zuriick-gebliebene  of  the 
Germans.  The  Koran  gives  this  special  charge  to  the  faith- 
ful :  '  Give  not  unto  those  who  are  of  weak  understanding 
the  substance  which  God  has  appointed  you  to  preserve  for 
them,  but  maintain  them  thereout,  and  clothe  them  and  speak 
kindly  unto  them." 

"  The  first  recorded  attempt  to  educate  an  idiot  was  made 
in  the  year  1800  by  Itard,  the  famous  physician  in  charge  of 
the  National  Institution  for  the  deaf  and  dumb  at  Paris,  upon 
a  boy  known  as  the  Savage  of  Aveyron.  In  the  year  1818 
and  for  a  few  years  afterwards  several  idiotic  children  were 
instructed  in  the  American  Asylum  for  the  Deaf  and  Dumb 
at  Hartford,  and  fair  results  were  obtained.  In  1828  Ferret, 
of  the  Bicetre,  near  Paris,  attempted  to  teach  the  imbecile, 
and  his  success  was  also  fair.  In  1831  Fabret  tried  the  same 
at  the  Salpetriere,  and  in  1833  Voisin  founded  his  private 
school  for  idiots  in  Paris.  In  1837  Seguin,  the  pupil  of  Itard 
and  Esquirol,  took  under  his  protection  a  number  of  idiots 
and  instructed  them  at  his  own  expense.  Exiled  from  his 
native  France  during  the  revolution  of  1848,  he  came  to 
America,  where  he  was  instrumental  in  establishing  schools 
for  idiots  in  various  States.  In  1848  a  private  school  for  im- 
beciles was  opened  at  Barre,  Massachusetts,  by  Dr.  H.  B. 
Wilbur.  In  1851  the  State  of  New  York  appropriated  six 
thousand  dollars  annually  for  two  years  for  the  purpose  of 
establishing  a  school  for  imbeciles,  and  in  1853  the  school 
was  formally  opened.  Pennsylvania  was  the  third  State  to 
take  up  the  work,  and  in  1852  a  private  school  for  idiots  was 
opened  in  Germantown  by  Mr.  J,  B.  Richards,  of  Massachu- 
setts. This  school  was  incorporated  April  7,  1853,  as  the 
Pennsylvania  Training  School  for  Idiotic  and  Feeble-Minded 
Children,  and  in  1855  it  was  removed  to  its  present  site  at 
Elwyn.  The  Ohio  institution  at  Columbus  was  established  in 
1857,  the  Connecticut  School  for  Imbeciles  in  1855,  and  the 
Kentucky  School  at  Frankfort  was  opened  in  i860,  followed 
by  the  erection  of  a  school  in  Illinois  in  1865. 

*'  Thus,  in  1874,  twenty-six  years  after  the  recognition  of 

178 


FORTY    YEARS    IN    TJli':    MI':iJ)ICAL    PROFESSION 

the  fact  tli.'it  an  imbecile  could  be  trained,  institutions  liad 
been  established  in  seven  States.  At  the  present  time  there 
are  twenty-four  large  institutions  in  the  United  States  caring 
for  eight  thousand  four  hundred  and  ninety-four  children, 
besides  many  small  private  schools.  In  the  training  of  the 
feeble-minded  a  correct  classification  is  most  important.  As 
Wilbur  forcibly  put  it,  we  do  not  propose  t(^  create  or  supply 
faculties  absolutely  wanting,  nor  to  bring  all  grades  of  idiocy 
to  the  same  standard  of  development  or  discipline,  nor  to 
make  all  capable  of  sustaining  creditably  all  the  relations  of 
a  social  and  moral  life;  but  rather  to  give  to  dormant  facul- 
ties the  greatest  possible  development  and  to  apply  these 
awakened  faculties  to  a  useful  purpose  under  the  control  of 
an  aroused  and  disciplined  will.  At  the  base  of  all  our 
efiforts  lies  the  principle  that,  as  a  rule,  none  of  the  faculties 
are  absolutely  wanting,  but  dormant,  undeveloped,  and  im- 
perfect. Broadly  considered,  the  feeble-minded  are  divided 
into  two  classes, — the  imbecile,  improvable;  the  idiot,  unim- 
provable ;   which,  modified,  stands  thus  : 

"  I.  The  imbecile,  trainable  in  three  grades,  low,  middle, 
and  high, 

"  2.  The  moral  imbecile,  found  in  all  these  grades,  train- 
able only  under  rigid  custodial  care. 

"  3.  Idio-imbecile,  improvable  as  regards  cleanly  living, 
and  trainable  in  a  very  limited  degree. 

"  4.  The  idiot,  except  in  rare  cases  and  by  expensive  meth- 
ods, absolutely  unimprovable. 

"  The  imbecile,  the  only  trainable  class,  divides  into  low, 
middle,  and  high  grade.  The  first  of  these  may  be  brought 
to  give,  always  under  direction,  fairly  good  service  for  farm 
or  house,  if  training  be  begun  early,  before  apathy  or  indo- 
lence becomes  a  settled  habit.  He  rarely  if  ever  learns  to 
read,  and  very  soon  reaches  his  mental  limit.  The  imbecile 
of  middle  grade  is  capable  of  making  slow'  progress  in  pri- 
mary school  work.  I  might  say  in  about  four  years,  especially 
if  he  has  had  previous  training  in  the  kindergarten,  he  will 
attain  some  proficiency  in  reading,  w-riting,  and  number  work, 

179 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

together  with  such  a  knowledge  of  form,  color,  and  practice 
in  free-hand  drawing  as  shall  materially  aid  him  in  learning  a 
trade.  Indeed,  mental  development  for  him  is  best  attained 
through  simple  handicrafts  having  their  initiative  in  the  kin- 
dergarten. 

"  The  high  grade  shows  children  but  slightly  mentally  defi- 
cient, who  progress  slowly  as  far  as  the  ordinary  grammar- 
school  grade,  frequently  developing  an  aptitude  for  music, 
drawing,  and  the  various  industries.  These  are  the  backward 
children  that  the  schools  complain  of,  the  feebly  gifted  ones 
of  England,  the  '  Tardivi'  of  Italy,  les  enfants  arrieres  of 
France.  These  are  they  so  often  not  recognized  in  seminary 
or  college  life,  until  under  excessive  pressure  or  excitement 
of  competition  comes  complete  breakdown,  idioc)^  insanity, 
or  early  death.  So  nearly  normal  are  many  of  these,  that 
their  defect  would  perhaps  be  noticed  only  by  the  initiated, 
and  the  question  is  often  asked,  why  are  these  who  do  so  well 
accounted  feeble-minded?  The  public  little  knowing  that 
the  time  and  labor  has  been  double  that  expended  for  like 
results  with  a  normal  child. 

''  The  moral  imbecile,  generally  of  high  or  middle  grade, 
quick  of  apprehension,  crafty,  and  cunning,  or,  if  of  low 
grade,  sullen  and  cruel  often  to  brutishness,  absolutely  desti- 
tute of  the  moral  sense, — what  might  be  termed  immoral  or 
unmoral, — is  too  dangerous  an  element  to  be  permitted  in  the 
schools.  This,  the  saddest  victim  to  a  fatal  inheritance,  is 
he  who  claims  most  at  the  hands  of  society  and  who  gets  the 
least,  because,  precocious  and  often  abnormally  bright,  he  is, 
as  a  certain  jurist  once  delighted  in  saying,  '  The  kind  we 
hang.'  As  intellectual  training  does  but  add  to  his  armament 
of  ill,  for  him  should  be  provided,  within  strongly  guarded 
asylum  walls,  all  the  benefits  of  a  manual  training  school  and 
its  outcome  in  the  various  trades,  which  shall  at  once  give  vent 
for  his  superfluous  energy  and  render  him  self-supporting; 
but  this  should  be  coupled  with  all  the  ameliorations  of  cheer- 
ful living  that  humanitarianism  owes  to  this  scapegoat  for 
the  sins  of  others.     Hard  labor  and  life-long  sequestration  is 

i8o 


FORTY    YRAKS    IN    THR    MEDICAI.    PROFESSION 

the  only  medicine  for  his  ill,  a  disease  loo  often  fhic  to  the 
sins  of  a  normal  ancestry. 

"The  i(Ho-imhecile,  who,  as  the  name  implies,  partakes  of 
the  nature  of  hoth  the  ichot  and  tlie  imhecile,  is  generally 
undersized,  with  very  defective  speech  and  a  limited  vocabu- 
lary confined  to  a  few  scattered  words,  never  a  full  sentence ; 
his  improvement  is  hut  limited.  The  most  we  can  hope  to  do 
is  to  keep  his  nervous,  restless  fingers  employed  ;  he  can  some- 
times learn  to  knit,  to  weave  mats,  or  do  simple  housework, 
hut  never  to  read  or  write.  For  him,  as  for  the  idiot,  but 
little  can  be  done  beyond  giving  him  the  custodial  care  best 
adapted  to  his  peculiar  needs,  the  genuine  benefit  being  found 
in  the  family  relieved  of  such  a  burden,  as  it  has  been  com- 
puted that,  for  every  case  sequestrated,  two  if  not  more  mem- 
bers are  released  to  society.  The  idiot  is  usually  but  poorly 
developed,  and  in  most  cases  unable  to  stand  or  even  to  sit 
alone,  hardly  conscious  of  his  physical  needs ;  he  has  no  lan- 
guage but  a  cry;  he  rarely  learns  to  talk;  indeed,  in  all  my 
experience  of  idiocy,  do  I  recall  but  two ;  of  these,  one,  after 
much  effort,  was  able  only  to  speak  his  brother's  name,  and 
the  other  acquired  three  words  in  three  years. 

"  A  word  as  to  methods.  These,  based  upon  the  theories 
of  physiological  education  dictated  by  Pestalozzi,  Froebel. 
and  Rousseau,  were  first  successfully  practised  with  mental 
defectives  by  Itard  and  by  Seguin,  and  include  all  the  means 
that  modern  thought  and  experience  have  gathered.  Kinder- 
garten, nature  studies,  object-lessons,  Sloyd,  and  the  many 
occupations  included  under  the  name  of  manual  training  all 
lend  a  successive  and  continuous  stimulus,  the  one  underlying 
principle  and  aim  of  the  schools  being  to  induce  observation 
and  comparison  as  a  basis  of  thinking  and  doing.  Calisthen- 
ics and  military  drill  induce  physical  development  and  muscu- 
lar co-ordination,  quick  observation,  and  prompt  subordina- 
tion. These  vital  principles  of  physiological  education  have 
practical  and  intellectual  application  in  the  exercises  in  free- 
hand drawing,  modelling  in  clay  and  wood,  in  Sloyd.  in 
basket  and  straw  braiding,  and  in  the  phonetic  and  articula- 

i8i 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

tion  drills  and  musical  exercises  of  the  class-room,  each  being 
the  initial  of  a  life-long  occupation. 

"  Believing,  as  we  do,  that '  the  working  hand  makes  strong 
the  working  brain,'  there  is  always  something  for  the  child 
to  do,  some  object  to  be  made,  not  an  abstract  thing  to  be  put 
out  of  sight  when  finished,  but  something  of  use  to  himself 
or  to  one  for  whom  he  cares.  Work  constantl)^  stimulated 
through  the  emotions  is  his  all  along  the  line,  from  kinder- 
garten, class-room,  and  Sloyd,  to  shoe-shop,  printing-office, 
and  other  useful  trades.  Should  his  limit  of  application  be 
soon  reached,  and  the  avenue  of  happiness  and  safe  living  be 
for  him  reduced  to  one  simple  groove,  the  more  active  pur- 
suits of  the  farm,  the  garden,  laundry,  or  household  service 
will  interest  and  provide  vent  for  superfluous  energy,  or  by 
constant  stimulus  keep  him  from  retrograding  or  lapsing  into 
apathy.  For  these  varied  occupations  he  is  all  the  better  fitted 
by  the  previous  training  of  the  senses  received  early  in  the 
schools,  and  if,  happily,  he  should  have  there  learned  to  read 
or  to  draw,  to  color,  to  carve,  or  has  acquired  any  skill  in 
music,  he  will  have  many  avenues  of  recreation  closed  to  his 
less  fortunate  brother,  to  whose  comfort  and  pleasure  he  him- 
self will  be  the  better  able  to  minister. 

"  In  regard  to  the  medical  treatment  of  mentally  defective 
children,  the  treatment  is  not  essentially  different  from  that  of 
the  normal,  except,  perhaps,  they  are  not  so  sensitive  to  drugs, 
and  we  generally  increase  the  doses.  They  need  many  tonics, 
and  I  find  that  punch,  or  even  plain  whiskey,  combined  with 
strychnine,  quinine,  and  iron,  is  about  the  best.  They  are 
peculiarly  susceptible  to  lung  and  cutaneous  diseases.  Some 
ten  years  ago  the  medical  world  was  agog  with  accounts  of 
brains  liberated  from  compressing  skulls  by  the  surgeon's 
knife.  The  press  was  filled  with  sensational  articles  on  the 
subject  of  craniectomy,  and  every  alienist  caring  for  feeble- 
minded children  was  besieged  with  applications  from  parents, 
who,  notwithstanding  the  certain  risks  attending  surgical  in- 
terference, begged  that  the  operation  might  be  tried  upon 
their  children.    I  have  seen  a  number  of  cases  operated  upon, 

182 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

and  in  only  one  case  have  I  seen  the  shghtest  improvement, — 
this  an  idiot,  to  whom  I  have  referred  before  in  these  notes  as 
having  learned  three  words  in  three  years.  Was  this  post 
hoc  or  propter  hoc  ? 

"  We  must  always  take  into  consideration  the  amount  of 
extra  care  a  child  recjuires  after  an  operation.  While  abroad 
I  examined  with  Bourneville  the  mag-nificent  collection  of 
skulls  operated  upon  at  the  Musee  Anatomo  Pathologique  of 
the  Bicetre,  and  the  skulls  healing  without  enlargement  show 
the  hopelessness  of  the  operation.  Victor  Horsley,  Shuttle- 
worth,  Beach,  and  Telford  Smith  agree  with  the  rest  of  us  in 
the  opinion  that  it  is  the  brain  that  moulds  the  skull,  not  the 
skull  the  brain." 

THE  DEAF  AND  DUMB. 

There  is  another  most  interesting  class  of  unfortunates,  the 
deaf  and  dumb.  In  1890  the  census  of  the  United  States 
showed  that  there  were  over  forty-one  thousand  of  such  peo- 
ple in  the  country.  Much  has  been  and  is  being  done  for 
their  comfort,  education,  and  training.  Millions  of  dollars 
have  been  expended  in  buildings,  and  now  almost  every  State 
of  the  Union  has  its  training-school  for  the  deaf  and  dumb, 
and  the  Gallaudet  College  for  the  deaf,  at  Washington,  D.  C, 
which  grants  diplomas  and  degrees,  after  a  full  college  course, 
is  a  fitting  monument  to  the  country  and  to  the  great  men  who 
founded  it.  The  first  record  of  efforts  to  teach  the  deaf  and 
dumb  in  this  country  was  by  Colonel  William  Boiling,  in 
Goochland  County,  Virginia,  in  the  year  181 2.  Colonel  Boi- 
ling had  three  deaf  children,  and  employed  John  Braidwood, 
a  Scotchman,  a  grandson  of  Thomas  Braidwood,  who  had  a 
school  for  the  deaf  and  dumb  in  Scotland.  Colonel  Boiling 
did  much  for  Braidwood,  but  his  intemperate  habits  rendered 
him  worthless  for  practical  work. 

The  real  introducer  of  successful  teaching  of  the  deaf  and 
dumb  into  the  United  States  was  that  distinguished  man, 
Thomas  Hopkins  Gallaudet,  and  the  place  Hartford.  Con- 
necticut. His  first  pupil  was  Alice  Cogswell,  a  daughter  of 
Dr.  Mason  F.  Cogswell,  of  that  citv.     Dr.  Gallaudet  has  a 

183 


FORTY   YEARS    IN    THE    MEDICAL    PROFESSION 

worthy  successor  in  his  son  Edward  Miner  Gallatidet,  Ph.D., 
LL.D.,"  the  distinguished  head  of  the  Gallaudet  College  for 
the  deaf,  at  Washington,  D.  C,  and  to  whom  I  am  indebted 
for  the  data  I  am  using  in  this  writing.  Hon.  Amos  Kendall 
should  not  be  forgotten  in  this  connection,  for  it  was  from  his 
goodness  of  heart  that  the  first  funds  and  efforts  were  sup- 
plied towards  the  establishment  of  this  great  institution. 

In  America  at  present  there  are  many  able  and  eminent 
men  engaged  in  educational  work  among  the  deaf  and  dumb, 
and  in  addition  to  those  already  mentioned  I  may  name  Dr. 
Crouter,  of  the  Philadelphia  Asylum  at  Mt.  Airy,  Peet, 
Rogers,  Gillett,  Noyes,  and  Fay,  connected  with  different 
institutions.  Why  are  so  many  children  deaf  and  dumb? 
That  is  what  concerns  us  as  physicians.  Can  we  as  physicians 
do  anything  to  prevent  it?  Doubtless  in  many  cases  we  are 
at  fault,  not  by  doing  harm  directly,  but  possibly  by  neglect 
and  careless  indifference.  Physicians  should  watch  infants 
under  their  care  during  the  first  few  days  after  birth,  and  see 
that  nurses  understand  something  of  the  anatomy  and  pathol- 
ogy of  the  ear.  A  child  may  be  kept  in  a  draught  of  cold  air, 
and  acute  inflammation  may  arise  and  do  serious  harm;  or 
water  may  be  carelessly  thrown  into  the  ear  by  the  nurse 
whilst  washing  the  child,  and  may  pass  back  to  the  mem- 
brane, remain  there,  and  cause  pain  and  inflammation,  and 
end  by  serious  disaster  to  the  hearing,  or,  by  passing  to  the 
brain,  to  life  itself.  Inflammation  from  a  catarrhal  cold,  or 
from  teething,  may  extend  to  the  ear  and  cause  great  trouble. 
Thus  it  behooves  the  physician  to  be  always  watchful  of  such 
conditions,  which  may  arise  at  any  time  and  in  any  case. 

As  to  the  methods  of  teaching  the  deaf  and  dumb,  the 
manual  method  prevailed  entirely  up  to  the  year  1867,  and 
very  little  speech  was  taught.  Since  that  time  great  progress 
has  been  made,  especially  in  speech.  It  seems  strange  that 
the  deaf  and  dumb  should  both  hear  and  talk,  but  practically, 
now,  they  do  both,  and  the  lips  are  helping  out  the  hands  in 
the  work.  A  deaf  mute  can  now  deliver  an  oration  that  would 
do  credit  to  a  Demosthenes  or  to  a  Webster.     Speech  will  not 


FORTY    YEARS    IN    TIN".    MICDICAL    PROFESSION 

take  the  place  of  the  iiiaimal  nietlifKl,  nor  will  the  manual 
method  entirely  prevail.  The  present  American  method, 
which  is  doubtless  the  best  in  the  vvorUl  to-day  after  thirty 
years  of  trial,  is  the  combined  system,  in  which  the  best 
effects  of  both  methods  may  be  secured.  In  all  the  schools  of 
the  United  States  to-day  every  pupil  is  given  an  opportunity 
to  learn  to  speak,  and  with  these  pupils,  where  substantial 
success  cannot  be  attained  after  examination  and  fair  trial, 
instruction  in  speech  is  not  continued.  As  far  as  I  can  ascer- 
tain, probably  less  than  one-half  the  deaf  and  dumb  are  taught 
speech  so  as  to  use  it  with  practical  success. 

Many  methods  have  been  brought  to  bear  upon,  and  are 
used  in  the  treatment  of  those  suffering  from  general  nervous 
troubles  which  not  many  years  ago  would  have  been  looked 
upon  as  doubtful  in  every  way,  as  verging  on  quackery,  or 
even  on  the  supernatural.  The  movement  cures,  as  first 
taught  in  Sweden,  have  been  made  wonderfully  effective ;  all 
forms  of  the  bath  are  used ;  electricity  and  the  masseur  and 
masseuse  are  in  constant  demand  and  doing  acceptable  and 
effective  work.  Learned  professors  hold  seances  frequently, 
and  mesmerism,  now  dignified  by  the  name  of  hypnotism, 
is  brought  into  frequent  and  useful  therapeutic  use.  This  is 
right  and  as  it  should  be.  Whatever  this  potent  influence  is. 
whatever  hypnotic  suggestion  may  be,  it  should  be  taken  from 
the  hands  of  the  charlatan,  the  magnetic  healer,  the  mesmeric 
doctor,  and  used  by  legitimate  medical  men.  If  you  ask  for 
a  definition  of  electricity,  now  so  much  and  so  deservedly  and 
successfully  used  as  a  therapeutic  measure,  the  answer  is,  '  a 
subtle  fluid.'  Any  answer  as  to  what  hypnotism  is  will  prob- 
ably convey  nothing  more  definite.  It  is  spoken  of  as  animal 
magnetism,  as  partial  cerebral  inhibition,  sleep  produced  in 
one  waiting  anxiously  for  suggestions  from  another,  or  any 
condition  produced  by  the  same.  We  have  it  under  the  name 
of  telepathy,  or  mind  reading,  the  motility  of  the  neuron  to 
explain  it.  and  here  we  are  again. — the  motility  of  the  neuron 
may  be  a  subtle  fluid,  and  that  is  about  all  we  know  of  this 
force.    After  all,  it  and  electricity  may  be  one  and  the  same. 

185  ' 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Hypnotism  has  been  practised  in  the  East  for  centuries, 
and  has  there  great  influence  on  the  ignorant,  and  is  thus 
used  to  sway  the  minds  of  men,  and  not  with  the  higher  ther- 
apeutic aim.  Probably  we  see  its  result  every  day  and  do  not 
recognize  it.  The  influence  of  one  man  over  another,  or  over 
many  men,  in  personal  matters,  in  religious  matters,  in  politi- 
cal matters,  in  social  and  other  matters,  is  undoubtedly  hyp- 
notic, a  result  of  hypnotic  suggestion.  In  nervous  diseases 
its  action  is  little  short  of  miraculous,  and  here  it  finds  often 
willing  subjects.  Whether  it  exerts  any  permanent  influence 
for  good,  as  in  the  case  of  the  dipsomaniac  or  other  victims 
of  the  passions,  I  am  not  personally  sufficiently  informed  to 
answer.  The  mistake  is  to  look  on  it  as  a  panacea.  That  it 
reaches  some  cases  not  reached  by  drugs  there  is  no  doubt. 
There  may  be  danger  in  it.  Harmful  suggestions  may  be 
given,  but  it  probably  does  not  weaken  the  will.  Possibly 
the  best  subjects  are  those  with  weak  wills,  and  these  are  the 
ones  whom,  as  a  rule,  hypnotism  may  benefit  and  who  suffer 
from  such  troubles  as  are  relieved  by  hypnotic  suggestion. 

One  of  the  great  problems  confronting  us  is,  what  to  do 
with  the  defective  classes,  or,  rather,  how  shall  we  stop  their 
increase  and  reproduction?  We  well  know  they  are  rapidly 
increasing,  and  increasing  in  proportion  far  more  rapidly 
than  the  race  is  increasing.  There  are  many  ways  to  account 
for  this :  the  increase  in  luxurious  living  and  general  invita- 
tions for  dissipations,  with  absolute  lack  of  restraint  by  the 
State  on  the  marriage  law  and  the  violations  of  the  marriage 
rite,  both  by  omission  and  commission.  Epileptics  are  in- 
creasing, the  insane  are  increasing,  the  dangerous  classes  are 
increasing;  in  fact,  all  degenerates,  all  moral  imbeciles,  are 
increasing  at  a  startling  rate.  These  cases  are  all  cases  below 
the  type  of  normal  man,  and  because  of  them,  and  for  them, 
this  great  branch  of  medicine  has  developed  and  grown  up. 
The  magnificent  race  of  Spartans,  or  Lacedaemonians,  of  an- 
cient Greece  was  made  in  a  manner  possible  by  allowing  only 
the  fit  to  survive.  Even  to-day  among  us  the  question  of 
unsexing  the  defectives  in  early  life  is  discussed;    not  only 

i86 


FORTY    YEARS    IN    TllIC    Ml'JMCAL    I'ROFESSION 

behind  closed  doors,  it  is  talked  of  and  advocated  openly,  yes, 
has  been  actually  practised,  with  asserted  good  effect  to  the 
individual  and  surely  to  posterity,  to  the  evolution  of  a  perfect 
race. 

Under  the  defectives  come  the  tuberculous,  and  particularly 
to  these  should  apply  the  supervision  of  the  marriage  laws  by 
the  State,  argue  the  advocates  of  such  supervision,  and  there 
is  no  doubt  of  the  soundness  of  their  arguments,  as  we  now 
understand  the  pathology  of  this  the  greatest  scourge  to  man- 
kind. y\ll  this  matter  of  heredity  comes  in  under  this  law 
of  advance  or  retreat  from  the  normal  type.  The  syphilitic, 
— and  with  the  syphilitic  should  go  gonorrhoea,  the  other  vene- 
real type,  which  we  now  know  causes  untold  suffering  and 
race  degeneracy,  through  the  female  particularly,  and  she  not 
the  sinner,  either, — the  alcoholic,  the  drug-taker,  all  tend  to 
lower  the  tone,  the  type,  and  the  vigor  of  the  race,  and  come 
under  the  neurotic  class.  It  is  the  part  of  the  physician  to 
care  for  and  improve  the  condition  of  these  unfortunate 
beings,  and  by  building  up  this  great  system  of  medicine  de- 
voted to  nervous  diseases  most  nobly  has  he  accomplished  his 
task,  and  most  nobly  does  he  continue  to  expand,  to  improve, 
and  to  unfold  his  work. 

This  is  not  all  that  interests  mankind  in  the  work  of  de- 
struction of  the  race  now  surely  going  on.  even  to  the  threat- 
ening of  the  extinction  of  the  normal  type.  Can  the  increase 
of  the  defective  classes  be  restrained?  That  is,  can  they  be 
restrained  in  the  reproduction  of  their  kind,  and  can  the  nor- 
mal type  be  restrained  from  producing  abnormal  and  not  the 
normal  type?  These  are  the  problems  confronting  us.  these 
are  the  problems  confronting  the  physician,  the  alienist,  the 
statesman.    Wg  must  grasp  them ;  posterity  must  solve  them. 


tS7 


CHAPTER    VUI. 

Ptomaines — Definition  of,  etc. — Composition  of,  etc. — Vegetable  Alkaloids 
— Changed  Food  Supply — Canning,  etc. — Poisonous  Gases  in  the  Sys- 
tem— The  Different  Ptomaines — A  Growing  Evil — Fatigue  and  Pto- 
maine Poisoning  —  Chronic  Ptomaine  Poisoning  —  Ice-Cream  and 
Cream-Puff  Poisoning — Personal  Experience  in  Ptomaine  Poisoning 
— Auto-intoxication  in  Disease — The  Reflexes  from  Ptomaine  Poison- 
ing and  Auto-intoxication — Pathogenic  Poisons — The  Death  Struggle 
an  Auto-intoxication. 

Among  the  most  interesting  matters  brought  to  the  atten- 
tion of  the  medical  profession  in  recent  years  is  the  knowl- 
edge of  the  presence  of  what  are  called  ptomaines  in  organic 
food-products,  and  much  of  this  work  has  been  done  by 
Vaughan  and  other  scientists  in  this  country.  Billing's  defi- 
nition of  a  ptomaine  is  that  it  is  a  strongly  basic  compound, 
the  result  of  putrefactive  changes  in  animal  tissues  closely 
simulating  vegetable  alkaloids.  It  may  be  liquid,  containing 
no  oxygen,  and  of  peculiar  cadaveric  odor,  or  solid,  crystal- 
lizable,  containing  oxygen,  soluble  in  water  but  insoluble  in 
alcohol,  chloroform,  etc.  All  ptomaines  are  precipitated  by 
phosphomolybdic  acid,  but  there  is  as  yet  no  general  test  dis- 
tinguishing ptomaines  from  vegetable  alkaloids.  They  all 
have  conspicuous  reducing  power.  Here,  observe,  is  a  cada- 
veric alkaloid.  Now  let  us  give  Billing's  definition  of  a  vege- 
table alkaloid.  It  is  an  organic  basic  substance  in  its  behavior 
with  acids,  resembling  ammonia.  They  all  contain  nitrogen, 
and  are  the  active  principles  of  most  poisonous  plants.  Here, 
then,  are  two  great  sources  of  poison  to  human  beings  always 
present  with  and  surrounding  us ;  given  large  doses,  and  the 
acute  attack  makes  known  at  once  their  presence ;  given  small 
and  constantly  repeated  doses,  and  chronic  poisoning  besets 
us.  Just  this  danger  confronts  us  in  these  cadaveric  alkaloids. 
It  is  not  the  large  dose  and  acute  poisoning  that  is  so  threat- 
ening, but  it  is  the  constant  small  dose,  the  coup  sur  coup,  the 
blow  upon  blow,  that  is  undermining  the  health  of  so  many 


FORTY    YIOARS    IN    THE    MJ':i>>ICAL    I'KOFESSION 

of  the  human  race  at  the  present  day  and  makes  their  acti(jn 
so  much  hke  the  slow  poisoning  we  often  see  in  the  con- 
sumers of  the  vegetahle  alkak)i(ls,  as  tliose  frfjm  opium  ruid 
otlier  phuits,  like  the  nicotine  from  tobacco;  they  cause  the 
slow  poisoning,  the  weakened,  intermitting  heart,  which  al- 
lows a  slight  regurgitation  of  blood  through  the  imperfectly 
closed  valves,  thus  preventing  complete  oxidation  in  the  lungs, 
and  allowing  poisonous  gases  to  accumulate  in  the  system. 

The  great  change  in  handling  the  food-supply  of  the  more 
advanced  countries,  the  system  of  cold  storage,  the  system  of 
canning  or,  as  the  English  say,  of  tinning  the  animal  foods, 
all  tend  to  the  increase  of  ptomaines  in  such  supplies,  for 
although  in  canning  the  bacteria  are  destroyed  by  heat  and 
the  contents  once  sealed  hermetically  will  remain  sound  until 
again  exposed  to  the  air,  the  ptomaines,  if  present  at  canning, 
are  not  destroyed  by  the  process,  and  remain  to  taint  those 
eating  them.  The  mere  fact  that  meats,  fish,  milk,  and  such 
products  are  kept  much  longer  before  consumption  than  for- 
merly, even  though  our  methods  of  preservation  are  so  im- 
proved and  superior,  makes  us  all  more  exposed  to  these 
poisonings.  Such  discoveries  are  causing  the  art  and  the 
science  of  medicine  to  be  rewritten,  just  as  chemistry  and 
electricity  have  been  and  are  being  rewritten. 

As  to  the  origin  of  ptomaines.  I  am  not  certain  that  we 
know  surely  about  it.  They  have  been  isolated  and  named, 
many  of  them,  as  tyrotoxicon,  or  cheese  poison,  found  in 
milk ;  halichthytoxin,  found  in  fish ;  mytilotoxine,  found  in 
mussels,  and  others.  Some  deny  that  ptomaines  are  the 
product  of  putridity  and  that  the  matter  in  which  they  exist 
is  necessarily  tainted.  From  what  I  know  of  them  I  am  in- 
clined to  believe  that  ptomaines  are  alkaloids,  the  result  of 
bacterial  action  in  matter  undergoing  putrefactive  change.  I 
have  seen  one  definition  of  them  as  of  one  of  the  temporary 
forms  through  which  matter  passes  in  changing  from  bacte- 
rial life  to  dead  inorganic  matter.  This  makes  them  the 
result  of  bacterial  action  whatever  the  cause.  I  have  no  doubt 
but  that  their  increased  presence  is  due  to  the  changed  meth- 

i8q 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

ods  in  handling  the  general  food-supply,  to  filth,  to  lack  of 
attention  to  details  in  large  packing  and  canning  establish- 
ments, to  long  distances  by  which  food  products  reach  the 
consumer,  and  last,  but  not  least,  to  the  rapid  increase  of  pop- 
ulation in  the  great  centres,  producing  the  classes  of  people 
likely,  owing  to  their  condition  and  environment,  to  furnish 
numerous  subjects  for  these  poisons.  It  is  doubtless  a  grow- 
ing evil,  and  one  that  must  be  carefully  supervised  both  by 
the  medical  profession  and  by  the  police  power. 

Ptomaines  lurk  particularly  in  milk,  the  albumin  furnish- 
ing a  good  medium  for  the  growth  of  the  bacteria  which  give 
rise  to  them.  Take  out  the  fat  and  they  still  thrive,  for 
some  of  the  worst  cases  of  poisoning  I  have  seen  have  been 
from  buttermilk.  Put  aside  a  can  with  some  left-over  butter- 
milk, let  it  stand  twenty-four  hours,  and  then  fill  with  fresh 
buttermilk,  and  you  will  almost  surely  have  ptomaines  devel- 
oped. I  have  seen  severe  cases  from  the  tyrotoxicon  in  cream 
puffs.  Investigation  showed  me  lack  of  cleanliness  and  lack 
of  attention  to  the  details  of  cooking,  in  all  these  cases.  No 
maker  of  such  pastries  will  poison  his  patrons  who  is  abso- 
lutely careful  to  provide  good  and  reliable  materials,  and  who 
practises  absolute  cleanliness,  with  strict  attention  to  all  minor 
details  as  regards  place  and  utensils.  Ice-cream  frequently 
is  the  villain  causing  the  trouble.  Not  the  ice-cream  from  a 
first-class  place,  even  though  it  claims  to  be  such,  but  circus 
ice-cream,  picnic  ice-cream,  washed-over  ice-cream,  is  always 
the  offender. 

As  to  the  chemical  nature  of  ptomaines  we  know  but  little, 
and  it  follows  we  as  yet  know  of  no  antidote.  Some  crystal- 
lized substances  have  been  found,  and  various  fungi  or  fun- 
gous growths,  differing  as  their  hosts  differ.  In  the  acute 
cases  I  have  seen  the  symptoms  have  been  usually  about  the 
same, — nausea,  vomiting  of  frothy  fluid  in  profusion,  free 
purging,  with  thin  soapy  stools,  anxious  countenance,  with 
great  pallor,  sweating,  and  pain  in  the  bowels,  in  fact,  a  gen- 
eral tendency  to  collapse.  The  feeling  of  fatigue  and  exhaus- 
tion are  referred  now  by  some  physiological  chemists  to  a 

190 


ii'Ok'I'V    VI'.AKS    IN    Till'.    i\I1'J)I(.;AI,    I'KCJl'I'.SSlOX 

form  of  ligliL  pUjiiiaiuc  poison,  making  il  rather  in  its  milder 
forms  purely  a  physiological  act,  and  a  regular  storm  of  it 
is  when  it  passes  the  danger  line.  The  treatment,  of  course, 
is  to  get  rid  of  the  offending  matter  from  the  digestive  tract 
in  all  possil)le  ways,  drinking  warm  water,  washing  out  the 
stomach  and  bowels,  and  supporting  the  heart,  above  all 
things,  while  nature  is  making  her  desperate  fight  for  su- 
premacy. Collapse  and  coma  may  end  the  scene,  but  in  my 
experience  death  is  not  frequent  in  these  acute  cases  where 
the  heart,  liver,  and  kidneys  are  sound,  the  efforts  of  nature, 
with  the  little  assistance  we  can  give,  generally  proving  ef- 
fective. 

What  shall  I  say  of  the  chronic  cases  ?  Well,  I  don't  know, 
but  I  know  enough  to  warn  the  profession  to  be  on  its  guard 
and  to  take  into  consideration  chronic  ptomaine  poisoning  as 
one  of  the  coming,  one  of  the  dangerous,  one  of  the  threaten- 
ing ills  of  mankind.  By  a  strange  coincidence,  just  after  I 
had  written  the  foregoing  I  myself  had  a  personal  experience 
with  ptomaine  poisoning.  I  had  been  well  and  very  busy. 
At  about  eight  o'clock  in  the  morning  I  ate  a  light  breakfast, 
consisting  of  a  small  portion  of  boiled  mackerel,  surely  not 
over  a  tablespoonful,  eating  it  with  stale  bread,  and  butter  to 
give  the  bread  a  flavor.  This,  with  a  cup  of  coffee,  composed 
my  breakfast.  At  ten  o'clock  I  left  my  office  and  was  busy 
out  and  in  my  carriage  for  five  hours.  When  I  came  home  I 
had  a  natural  movement  of  the  bowels,  when  a  slight  nausea 
came  on,  with  a  tendency  to  taste  the  fish.  I  took  no  luncheon, 
and  rarely  do.  The  nausea  increased,  and  by  the  time  my 
usual  dinner-hour  (six  o'clock)  came  I  was  very  sick,  vomit- 
ing and  purging,  more  particularly  purging,  continuously.  I 
may  say,  before  this  commenced,  coincident  with  the  onset  of 
the  nausea,  I  noticed  attacks  of  irregular  heart-action  and  in- 
termitting heart.  As  I  grew  worse  the  intermitting  and 
rapid  heart-action  increased,  and  before  I  commenced  to  come 
around  I  was  verv  weak  generally.  For  fifteen  hours  the 
purging  kept  up,  a  passing  of  thin,  soapy,  frothy,  almost 
colorless,  looking  fluid,  perfect  rice-water  discharges.    I  could 

TQI 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

not  imagine  one  passing  more  in  quantity  during  the  same 
length  of  time.  There  was  great  general  uneasiness  in  the 
stomach  and  bowels  throughout  the  attack,  but  only  for  a  time 
was  the  pain  very  severe,  when  a  true  colic  came  on,  which 
was  relieved  by  vomiting.  After  the  diarrhoea  ceased  the 
nausea  remained  for  about  thirty-six  hours  from  the  com- 
mencement of  the  attack,  with  a  horrible  general  tight  binding 
headache.  The  temperature  never  went  over  ioo°  F.  Alto- 
gether I  was  inexpressibly  miserable,  and  had  I  been  on  a 
rack  of  torture  I  could  not  have  suffered  more  in  joints  and 
muscles  than  I  did.  The  mackerel  was  undoubtedly  the  cause 
of  the  trouble,  as  I  had  eaten  nothing  else  to  cause  it  during 
the  twenty-four  hours  preceding.  Fortunately  no  other  mem- 
ber of  my  family  partook  of  the  fish,  and  the  uncooked  part  of 
it  after  I  was  taken  ill  was  made  away  wath  before  I  was  able 
to  give  a  thought  to  its  examination. 

Having  spoken  of  ptomaines  and  their  actions  brings  us  to 
another  subject  germane  to  them,  and  one  of  very  great  im- 
portance to  both  physician  and  patient,  and  one  which  has 
but  recently  assumed  a  position  of  importance,  owing  to  the 
W'Ork  and  writings  of  Bouchard,  more  particularly.  I  refer 
to  auto-intoxication  in  disease,  or  self-poisoning  of  the  indi- 
vidual. This  is  one  of  the  parts  the  alkaloids  chiefly  play  in 
the  causation  of  disease  and  diseased  conditions  in  man,  and 
are  greatly  the  result  of  ptomaines  in  one  shape  or  another. 
We  would  probably  all  die  sooner  or  later  from  these  poisons, 
generated  from  complex  digestive  processes  going  on  chiefly 
in  the  small  intestines,  w^ere  it  not  from  the  fact  that  their  life 
is  self-limited,  being  destroyed  by  the  poisons  they  themselves 
generate,  thus  fulfilling  that  relentless  law  of  nature  that 
every  living  thing  generates  its  own  poison,  to  which  rule 
man  even  is  no  exception. 

According  to  Bouchard  self-poisoning  in  man  is  only  pre- 
vented by  the  action  of  the  liver  and  kidneys,  and  the  result- 
ing fluids  are  poisonous  as  they  pass  out  of  the  system.  The 
ferments  formed  outlive  their  parents,  the  bacteria.  Alienists 
are  now  giving  much  attention  to  the  part  auto-intoxication 

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FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

plays  in  mental  diseases.  The  injection  into  the  lower  ani- 
mals of  urines  of  those  suffering  from  different  types  of  in- 
sanity gives  results  characteristic  as  to  the  form  of  insanity. 
The  delirium  of  fevers  is  probably  much  of  it  owing  to  auto- 
intoxication from  pathogenic  organisms.  Bouchard  believes 
many  of  these  germs  are  innocuous  in  the  intestinal  tract  of 
the  animal  forming  them,  but  may  be  harmful  when  taken 
up  by  an  animal  of  another  kind.  The  white  blood-corpuscles 
may  destroy  them  and  the  liver  may  check  them.  Asphyxia 
is  an  intoxication. 

Uraemia  is  an  interesting  condition  to  all  observant  physi- 
cians. It  is  a  complete  intoxication  according  to  Bouchard. 
Formerly  urea  was  considered  the  chief  or  only  poisonous 
agent.  Now  many  other  matters  are  known  to  be  more  the 
cause,  as  alkaloids,  and  are  found  as  extracts  in  evaporated 
urine.  Ammonia,  soda,  and  potash  are  poisons  in  urine. 
There  are  two  substances  causing  convulsions, — potash  and 
the  other  an  organic  substance.  If  this  is  correct,  how  im- 
portant to  avoid  potash,  in  all  renal  insufficiencies  particu- 
larly; substitute  iodide  of  sodium  for  iodide  of  potassium, 
and  avoid  potash  in  the  salines  so  much  used  in  renal  trou- 
bles. Putrefaction  plays  a  great  part  in  auto-intoxication, 
coming  from  imperfect  changes  in  digesting  matters,  and 
also  from  micro-organisms  in  the  intestinal  tube.  These 
are  the  nitrogenous  substances  already  peptonized,  which 
are  excellent  culture  media  for  microbes ;  additional  micro- 
organisms go  down  with  each  swallow  of  saliva  from  the 
dust  of  the  air.  etc.  Fermentation  does  not  go  on  continu- 
ally in  the  stomach,  because  the  hydrochloric  acid  which  is 
always  being  secreted  by  the  healthy  stomach  when  food  is 
being  introduced  stops  it ;  going  on  through  the  pylorus,  this 
acid  is  neutralized  by  the  intestinal  alkaline  fluids,  which  are 
only  feebly  acid,  when  acetic  fermentation  begins.  Bile 
only  feebly  opposes  fermentation  in  the  small  intestine,  and 
can  have  no  influence  on  the  active  fermentation  of  the  large 
intestine.  Thus  the  small  and  large  intestines  both  pass 
products  of  putrefaction  into  the  blood.  These  matters  are 
13  193 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

toxic;  they  enter  the  blood  and  act  at  once.  If  infectious, 
they  would  not  act  at  once,  for  infection  implies  time  for  in- 
cubation. We  find  the  alkaloids  in  the  fecal  contents  of  the 
large  intestine,  for  here  putrefaction  goes  on  unchecked  by 
any  jDresence  of  hydrochloric  acid.  Fecal  matter  is  toxic  in 
a  general  way  to  living  cells.  The  aqueous  extract  is  toxic; 
the  alcohol  extract  is  more  so.  Here  is  a  great  source  of 
auto-intoxication,  if  such  accumulations  are  allowed  to  re- 
main beyond  the  proper  time.  Let  the  kidneys  be  diseased, 
and  here  is  another  prolific  source  of  intoxication.  They 
may  be  doing  badly  and  the  patient  do  pretty  well.  If  they 
be  diseased  so  much  as  no  longer  to  eliminate  in  twenty-four 
hours  the  quantity  of  poison  sound  kidneys  should  eliminate 
in  this  time,  the  consequences  must  be  serious.  Sound  kid- 
neys can  do  more  than  is  normally  required  of  them,  as  in 
the  amount  of  water  they  eliminate  in  diabetes.  They  may 
go  further;  they  may  eliminate  substances  that  should  not 
come  off  by  them,  as  peptones  and  albumin,  and  the  blood  is 
impoverished.  Twelve  grammes  in  twenty-four  hours  is 
much  albumin  to  lose  by  the  kidneys,  especially  if  we  do  not 
recruit  it  by  healthy  digestion.  The  poverty  of  the  blood 
caused  by  these  intoxications  is  frequently  the  cause  of  retini- 
tis, amaurosis,  phlegmons,  oedema  of  the  glottis,  hemor- 
rhages, and  such. 

These  auto-intoxications  of  intestinal  origin  come  chiefly 
from  reabsorption  from  the  intestines.  Constipated  people, 
as  a  rule,  all  suffer  from  such,  and  among  them  vertigo,  dizzi- 
ness, headaches,  disturbances  of  sight,  etc.,  are  common. 
Many  are  hypochondriacal.  Among  the  insane  are  many  suf- 
ferers; some  may  have  almost  constant  diarrhoea  and  yet  be 
sufferers  from  accumulated  masses  in  the  large  intestines. 
Diarrhceal  discharges  may  pass  through  a  hole  bored  through 
the  centre  of  such  masses,  making  quite  a  lumen.  Wash 
out  the  bowels  fully  and  often  is  the  remedy,  using  antisep- 
tic injections.  Common  salt  is  among  the  best  and  safest. 
Be  careful  of  carbolic  acid  in  large  doses.  The  danger  in  its 
use  does  not  often  compensate  for  its  advantages. 

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FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

After  such  trc'itnicnt  fevers  will  f)ftcn  abate  and  comfort 
return  to  your  ])atienls.  Many  of  these  people  have  dilated 
stomachs.  Treat  such  stomachs  hy  diet,  and  locally  wash 
them  out  as  you  wash  out  the  bowels,  and  improvement  and 
cure  comes.  In  dilated  stomachs  we  liave  all  sorts  of  fer- 
mentations, and  so  intoxications  and  reflex  troubles  come,  as 
headache,  urticarias,  and  such.  As  l^efore  said,  I  believe 
urticarias  and  such  are  vasomotor  neuroses  coming  from 
auto-intoxication  from  ptomaine  poisonings  of  more  or  less 
chronic  character.  Bouchard  speaks  of  a  form  of  dilated 
stomach,  accompanied  l)y  albuminuria,  the  albuminuria  being 
caused  neither  by  heart  nor  kidney  trouble.  In  the  treatment 
of  typhoid  fever  he  cautions  care  in  watching  for  ^uto-intoxi- 
cation,  and  believes  in  intestinal  antisepsis  here,  using  naph- 
thalin,  iodoform,  arid  carbolic  acid,  with  lavage  of  the  large 
bowels.  The  fever  causes  the  withdraw^al  of  the  blood-cor- 
puscles to  the  spleen,  and  thus  enlarges  it.  According  to  this 
we  should  have  enlarged  spleen  in  all  fevers. 

This  matter  of  intestinal  toxaemia  is  a  most  interesting 
subject,  and  its  development  and  elucidation  by  study  and 
observation  must  work  great  good  to  suffering  humanity.  It 
is  always  to  be  taken  into  account  in  the  diagnosis  of  fevers 
and  of  all  obscure  cases,  especially  the  enteric  fevers,  the 
fevers  arising  from  tuberculous  disease,  from  renal  troubles, 
from  slow^  poisonings  of  different  kinds,  especially  the  min- 
eral poisons,  and  from  litheemia  and  lith?emic  troubles.  It 
is  common  in  children,  more  especially  in  bottle-fed  children. 
Here  in  the  retained  matters  in  the  intestines,  both  large  and 
small,  we  have  fermentation  and  putrefaction  going  on  with 
the  formation  of  acids,  as  butyric  and  lactic;  gases  are  also 
developed;  these  pressing  on  the  filaments  of  the  pneumo- 
gastric  nerve  give  rise  to  local  troubles  and  also  to  reflex 
troubles  involving  the  brain  and  general  nervous  system. 
The  albumin  of  the  milk  and  other  nitrogenous  substances 
eaten  gives  rise  to  the  development  of  indol,  one  of  the  aro- 
matic series,  resulting  from  the  decomposition  of  albumin ; 
skatol.  ty rosin,  a  product  of  pancreatic  digestion ;    with  phe- 

195 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

nol  in  the  urine.  From  all  these  troubles  we  have  many  reflex 
symptoms  arising  and  expressed  in  bronchial  attacks,  local 
and  general  convulsions,  spasm  of  the  glottis,  circulatory  ir- 
regularities, with  skin  troubles  and  rashes  of  different  kinds. 
In  such  cases  do  not  forget  to  watch  the  kidneys,  remember- 
ing that  whatever  troubles  may  arise  in  them  are  usually 
functional.  Remember  the  cause  of  all  these  troubles  is  in 
the  digestive  tract.     Remove  it  and  the  cure  is  assured. 

Pathogenic  poisons  exist  in  the  sick  man,  and  the  death 
struggle  prolonged  is  an  auto-intoxication.  In  certain  dis- 
eases there  are  certain  morbid  poisons  engendered  by  the  nor- 
mal life  of  microbes  or  the  diseased  life  of  human  cells,  what- 
ever these  may  be.  Light  is  gradually  dawning  on  pathologi- 
cal conditions,  and  man  is  thus  paving  a  better  way  for  the 
rational  treatment  of  his  own  ills  and  the  prolongation  of  his 
own  life. 


196 


CHAPTER    IX. 

Diet  now  on  a  Scientific  Basis — Study  the  Individual — Idiosyncrasies — 
Teach  Diet  in  the  Schools — Diet  in  Youth  and  Old  Age — Carlsbad 
and  its  Doctors — Diet  and  the  Poor — Division  of  Foods — Animal  and 
Vegetable  Foods — Tissue-Builders  and  Force-Producers — Uses  of 
Food — Oxidation  and  Health — Water — Rations  for  Individuals — Chil- 
dren and  Proteids — Atwater  and  Woods  on  Composition  of  Foods — 
All  about  Eggs — Fish  compared  with  Beef,  etc. — White  Potatoes, 
Spinach,  Asparagus,  etc. — Lead  Poisoning — Coflfee  and  Tea — Choco- 
late and  Cocoa — Dietary  Studies  among  the  Plain  People — The  Ger- 
mans and  German  Thrift — Study  of  a  Family  as  to  its  Diet,  Cost  of, 
etc. — Diets  for  Corpulency  and  Leanness — Systems  of  Diet — Banting 
and  Others — Different  Kinds  of  Breads — Toast,  etc. — Kissingen  and 
Vichy  Remedy  for  Fatness — Food  consumed  per  Person  per  Year  in 
Different  Countries — Time  required  for  the  Digestion  of  Various 
Foods — Sterilizing  and  Pasteurizing  Milk — Infant-Feeding — Artificial 
Infant  Foods — Diet  for  the  Old — Ward  McAllister— Infantile  Scurvy 
— Concerning  Milk — Tests  for  Milk — Regulating  the  Milk  Trade — 
Graded  Milk. 

At  the  present  day  I  believe  the  profession  is  coming  more 
and  more  to  appreciate  the  importance  of  diet.  Surely  forty 
years  ago,  when  I  entered  the  profession,  little  was  said  about 
it  and  less  was  taught  concerning  it  in  the  medical  schools. 
All  or  nearly  all  at  that  time  believed,  empirically  believed, 
in  the  antiphlogistic  system  of  treatment,  and  almost  every 
sick  man,  or  wounded  man,  or  crazy  man,  for  that  matter, 
was  put  on  a  diet  of  as  near  bread  and  water  as  possible,  and 
because  women  were  fortunate  enough  to  have  babies,  for 
that  they  were  generally  starved  for  six  weeks,  much  to  their 
own  injury  and  the  inconvenience  of  the  luckless  offspring. 
Why  were  they  starved?  Oh,  to  prevent  inflammation. 
What  was  inflammation?  Too  much  blood.  Thanks  to 
Professor  W.  Oilman  Thompson,  Liebig.  Sir  Henry  Thomp- 
son, Fothergill.  Horatio  Wood,  and  others,  the  matter  of 

197 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

diet  to-day  has  advanced  from  mere  empiricism,  from  the 
mere  didactic,  thoughtless,  even  ignorant  assertions  of  the 
school  men,  to  something  approaching  an  exact  science,  and, 
like  general  therapeutics,  is  no  longer  a  mere  assertion  or 
pill-giving  calling,  but  is  a  well-studied  scientific  profession. 

Professor  Thompson's  recent  work  on  Practical  Dietetics 
is  a  timely  and  most  useful  gift  to  the  medical  profession, 
and  I  wish  here  to  acknowledge  the  generous  use  I  shall  make 
of  the  information  gained  from  its  pages  in  this  little  sketch 
of  modern  dietetics  I  am  writing.  When  we  order  this  thing 
and  that  thing  to  a  sick  person  to  eat,  do  we  do  it  thinkingly 
or  unthinkingly?  Surely  we  should  think  in  carbon  and  hy- 
drogen, oxygen  and  nitrogen.  Given  a  patient  with  con- 
tracted kidneys  and  hypertrophy  of  the  left  ventricle,  and 
other  ills  perchance  following  in  the  wake  of  these,  of  what 
use  is  medicine,  of  what  use  are  pills  and  powders  and  po- 
tions, if  we  allow  such  a  patient  to  stuff  himself  with  an 
excess  of  nitrogenous  food? 

These  are  cases  of  commencing  or  confirmed  arterioscle- 
rosis from  which  arise  aneurisms,  apoplectic  seizures,  and  so 
on.  The  first  symptoms  are  usually  increased  steady  heart 
action  and  an  excessive  flow  of  urine  of  low  specific  gravity, 
soon  followed  by  renal  contraction.  How  useless  are  medi- 
cines in  these  cases  if  the  eating  and  drinking  of  the  patient 
are  not  supervised  and  rigidly  controlled !  When  we  order 
our  pills  and  potions  and  powders  in  such  a  case,  let  us  think 
in  carbon  and  hydrogen  and  oxygen  and  nitrogen,  and  see  to 
it  we  do  not  increase  his  blood-pressure  by  food  whilst  we 
are  endeavoring  to  control  it  by  drugs.  In  such  a  case,  if  I 
must  abandon  one  course  of  treatment  and  keep  only  to  the 
other,  give  me  diet,  "  throw  physic  to  the  dogs." 

Another  practical  point  in  dietetics  is,  study  the  individual. 
It  is  very  true  that  what  will  nourish  one  man  will  poison 
another,  and,  further,  what  will  be  proper  for  a  well  man 
may  kill  a  sick  man.  Some  individuals  can  live  on  milk  alone 
when  they  try;  with  others  it  is  impossible.  Many  a  man 
can  eat  mutton  and  grow  fat  on  it,  so  he  can  eat  eggs  and 

198 


FORTY    YEARS    IN    'JIN'    MICDICAL    PROFESSION 

tlirivc;  to  others,  a^aiii,  these  are  poison.  Such  are  mere 
idiosyncrasies,  and  it  is  well  lo  remember  them.  I  believe 
the  principles  of  (het  and  nnlrilion,  the  effects  of  alcohol  and 
tobacco  and  such,  should  be  tausj^ht  to  some  extent  in  the 
schools,  not  fanatically,  but  reasonably.  Sf)me  general 
knowledge  on  this  score  would  add  much  lo  the  general 
health  of  a  people  and  be  of  assistance  to  physicians  in  treat- 
ing the  average  man.  There  is  a  diet  for  the  young,  for  the 
man  of  middle  age,  and  for  the  aged  ])erson.  We  commence 
with  milk,  the  complete  food,  the  balanced  ration.  We  go 
through  all  of  the  luxuries  of  a  lifetime,  and  as  we  approach 
toothless  old  age  we  come  back  again  to  childhood  and  to 
childhood's  ration,  milk,  and  in  extreme  old  age  the  nearer  we 
adhere  to  the  simple  milk  diet  the  better  and  happier  we  are, 
and  the  longer  and  more  satisfactorily  we  live.  My  observa- 
tion and  experience  lead  me  to  believe,  as  intelligent  persons 
grow  to  middle  age  and  beyond,  they,  as  a  rule,  become  care- 
ful as  to  diet.  Indeed,  many  become  cranky  or  full-fledged 
cranks,  especially  the  idle  and  well-to-do.  This  is  all  right 
so  they  do  not  a|)proach  melancholia.  These  people  are  the 
ones  who  often  take  and  who  often  benefit  by  the  course  at 
Carlsbad  and  such  resorts. 

I  do  not  approve  always  of  Carlsbad  diet  for  the  given 
case,  and  have  been  familiar  with  some  diagnoses  made  by 
resident  physicians  of  Carlsbad  that  I  did  not  by  any  means 
agree  with.  I  once  knew  of  an  ardent  temperance  woman 
who  took  her  young  son,  a  boy  of  seventeen,  to  Carlsbad, 
thinking  the  course  might  relieve  him  of  some  dyspeptic  trou- 
ble, too  many  sweets  in  his  diet,  probably.  She  called  with 
John  at  the  office  of  a  prominent  consultant,  who  was  very 
affable  and  very  painstaking,  asking  many  questions,  finally 
coming  to  diet.  "  Veil,  Shon,  vhat  do  you  drink?''  "  Drink," 
said  John.  "  Yes,  vhat  do  you  drink?"  "  Water,  of  course," 
answered  the  mother.  "  Nothing  stronger,  I  assure  you." 
"  Vaser!  Vaser!"  said  the  doctor,  in  wild  amazement.  "  My 
Got!  it  vill  kill  him.  madame ;  it  vill  kill  him."  It  is  safe  to 
say  madame  did  not  take  the  doctor's  advice  as  to  John's 

199 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

beverages,  and  left  Carlsbad  with  a  poor  opinion  of  its  doc- 
tors. 

There  is,  no  doubt,  much  suffering  from  improper  diet, 
and  bad  cooking  is  responsible  for  many  ills  and,  doubtless, 
many  deaths.  A  little  observation  of  the  inner  life  of  the 
poor  v^ill  cause  one  to  realize  in  a  high  degree  the  utter  dis- 
comfort and  utter  misery,  even  unto  death,  which  come  to 
those  untutored  and  unskilled  in  providing,  in  choosing,  and 
in  preparing  properly  for  the  table  even  the  simplest  of  foods. 
Education,  supervision,  the  evolution  to  a  higher  plane  of 
living  for  these  people  is  the  only  corrective  for  such  pitiable 
ignorance  and  carelessness.  These  people  need  supervision, 
they  need  instruction.  The  principles  of  cooking  practically 
taught  in  schools  would  help  out  in  this  work.  Call  it  pater- 
nalism if  you  choose,  but  as  we  grow  wiser  in  government 
such  matters  must  come  up  and  be  taken  up  before  we  reach 
the  highest  civilization. 

Thompson  divides  foods,  say,  into  solids,  semi-solids,  and 
liquids.  Next  into  fibrous,  gelatinous,  starchy,  oleaginous, 
and  albuminous.  He  speaks  of  eggs  and  milk  as  examples 
of  complete  foods  which  alone  will  support  life ;  others,  again, 
as  starches,  will  not  alone — absolutely  alone — support  life  for 
a  length  of  time.  The  sources  of  food  are  animal  foods  and 
vegetable  foods.  Animal  foods  are  meats,  poultry,  fish,  shell- 
fish and  crustaceans,  eggs,  milk  and  its  products,  animal 
fats,  and  gelatin.  Vegetable  foods  are  the  cereals,  vegetables 
proper,  fruits,  sugars,  and  vegetable  oils.  The  simplest  chem- 
ical classification  is  Liebig's  nitrogenous  and  non-nitroge- 
nous. The  nitrogenous  group  are  tissue-builders  or  flesh- 
formers.  The  non-nitrogenous  group  furnish  the  body  with 
the  fuel  and  keep  up  the  animal  heat,  and  are  the  force-pro- 
ducers. The  tissue-builders  also  produce  some  force  and 
heat.  There  is  some  nitrogen  in  the  vegetables,  though  not 
a  great  deal.  The  outside  coverings  of  the  starch  granules 
contain  some  nitrogen,  for  example.  Nitrogenous  foods  also 
are  not  absolutely  nitrogenous,  as  they  contain  some  fat  and 
glycogen.     The  uses  of  food  are  to  serve  the  body  with  ma- 


FORTY    YEARS    IN    Till':    MEDICAL    PROFESSION 

terials  for  <^rowth  and  renewal,  and  with  power,  much  as  fuel 
does  for  the  steam-engine.  The  consumption  of  the  fuel 
furnishes  the  power.  The  starches  and  sugars  furnish  much 
of  the  power  to  man.  The  original  force  is  in  the  heat  of  the 
sun;  this  is  stored  by  the  plants  in  the  latent  form  of  chemical 
compounds,  as  Professor  Thompson  says.  The  main  source 
of  power  is  oxidation,  chiefly  of  carbon.  Wherever  it  goes, 
or  any  waste  product  goes,  it  is  not  destroyed,  it  only  changes 
its  form ;  you  cannot  destroy  matter.  Take  urea :  it  is  mat- 
ter merely  of  our  food  in  a  changed  form,  something  like 
ashes  from  coal.  This  urea  and  other  debris,  if  not  gotten 
out  of  the  body,  blocks  the  system  and  prevents  the  normal 
processes  of  oxidation,  which  must  go  on  properly  to  give 
one  good  health. 

Thompson  says  it  is  still  difficult  to  trace  in  the  case  of  all 
foods  their  final  uses  in  the  body  and  determine  accurately 
what  proportion  of  each  goes  to  power,  what  proportion  to 
tissue  repair,  and  what  proportion  to  furnish  heat,  for  tissue 
metabolism  is  very  complex  in  its  chemistry.  The  daily  al- 
lowance of  nutritive  material  allowed  by  Professor  Egleston 
as  given  by  Thompson  for  a  healthy  man  is  seven  hundred 
grammes,  divided  into  carbohydrates,  four  hundred  grammes ; 
fats,  one  hundred  and  fifty  grammes;  proteid,  one  hundred 
and  fifty  grammes,  yielding  in  all  three  thousand  six  hundred 
and  fifty  calories,  or  units  of  heat,  a  heat  unit  being  the 
amount  of  heat  required  to  warm  one  gramme  of  water  one 
degree  centigrade. 

Water  is  to  be  looked  upon  as  food,  composing  as  it  does 
seventy  per  cent,  of  the  weight  of  the  body,  and  much  of  it 
passes  through  the  body  unchanged.  Withhold  it,  and  life  is 
impossible.  I  am  sure  as  a  remedy  it  is  not  half  appreciated. 
Many  persons  do  not  drink  water  enough,  and  suffer  accord- 
ingly, whether  sick  or  well.  Others,  again,  may  take  too 
much,  and  it  is  the  duty  of  the  physician  to  study  each  case 
and  set  his  patient  right  on  so  important  a  matter.  Of  course, 
much  of  the  water  we  take  goes  in  as  part  of  our  food,  and 
this  fifty  to  sixty  per  cent,  of  water  in  our  solid  foods  must 

201 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

be  taken  into  account.  The  salts,  such  as  lime  and  mag-nesia, 
abound  in  the  body,  and  they,  with  many  others,  have  their 
uses  in  tissue  formations,  etc. 

Thompson,  quoting  from  Von  Pettenkofer  and  Voit, 
shows  that  during  the  performance  of  hard  labor  the  con- 
sumption of  albumin  remains  practically  the  same  as  during 
rest,  whereas  three  and  one-half  times  as  much  fat  is  con- 
sumed, and  the  amount  of  carbohydrates  is  the  same,  hence 
for  hard  laborers  give  plenty  of  fat  pork,  butter,  oil,  and  such. 
A  workingman  will  take  from  fifty  to  seventy-five  ounces  of 
solid  food  in  twenty-four  hours,  and  about  the  same  amount 
of  w'ater  by  weight.  The  ration  should  contain  one  part  of 
nitrogenous  food  to  three  and  one-half  parts  of  non-nitroge- 
nous food.  The  average  albuminous  food  gives  about  six- 
teen per  cent,  of  nitrogen.  Again  quoting  Thompson,  for  a 
man  weighing  sixty-seven  kilogrammes  the  daily  allowance 
of  food  ranges  from  six  to  nine  grains  of  carbon,  and  .25  to 
.36  grain  of  nitrogen  per  kilogramme  of  body  weight.  Cow's 
milk  and  wheat  flour  approach  nearest  to  a  balanced  ration 
of  all  food  as  to  their  nitrogenous  and  non-nitrogenous  pro- 
portions. In  cow's  milk  the  proportion  is  one  to  three,  and  in 
W'heat  flour  one  to  four  and  one-half. 

These  are  matters  of  great  practical  importance,  and  all 
physicians  should  be  more  or  less  familiar  with  them.  The 
destruction  of  the  carbohydrates  in  the  body  is  very  complete 
when  eaten  in  excess,  and  they  do  not  produce  fat  like  fatty 
foods  taken  in  excess.  This  is  an  important  practical  point. 
The  carbohydrates  are  more  or  less  fattening  when  eaten  with 
albumin  and  fats,  because  they  check  the  consumption  of  al- 
bumin and  fats  and  leave  more  of  them  to  be  converted  into 
tissue  fats.  Eaten  alone  they  are  not  so  fattening.  For  ex- 
ample, the  Chinaman,  living  mostly  on  rice,  is  not  usually 
over-fat.  Another  practical  point :  when  you  have  children 
growing  rapidly  and  using  their  force  in  the  ceaseless  activity 
of  the  young,  see  that  they  get  sufficient  of  proteids  in  their 
daily  ration.  The  food  value  of  certain  articles  of  diet  is 
most  important  to  the  physician,  whether  to  make  up  a  ration 


FORTY    YEARS    IN    TTIK    MEDICAL    PROFESSION 

for  the  soldier,  for  the  laborer,  the  professional  man,  or 
women  or  ehildren,  or,  more  than  all,  of  the  sick  intrusted 
to  his  care.  (3f  alhiiniinons  matters  used  as  food,  one-third 
of  it  is  excreted  as  urea.  This  is  impf)rtant  to  remember 
when  the  kidneys  are  diseased  and  cannot  get  rid  of  this 
urea,  although,  as  before  said,  some  are  beginning  to  deny 
that  urea  unexcreted  is  the  great  offender  it  has  heretofore 
been  given  credit  for. 

Probably  most  persons  over  thirty-five  years  of  age  con- 
sume too  much  nitrogenous  food,  especially  those  who  inherit 
gout.  These  gouty,  bilious  people  are  usually  the  strong  and 
healthy,  and,  as  a  rule,  have  ravenous  appetites;  they  live 
to  eat,  rather  than  eat  to  live.  They  often  incline  to  be  good 
drinkers  of  wines,  spirits,  and  malt  licjuors,  but,  as  a  rule, 
much  to  their  disadvantage,  are  light  water-drinkers.  If 
they  drank  more  water  the  ill  effects  of  a  vicious  metabolism, 
of  vicious  tissue  change  in  nutrition  and  secretion,  would  be 
carried  out  of  the  system  more  generally  in  the  various  secre- 
tions and  excretions.  It  is  surprising  to  see  how  soon  one 
who  has  been  a  free  meat-eater  can  come  down  to  almost  a 
non-nitrogenous  diet  and  enjoy  life  and  feel  lighter  and  better 
and  more  contented  in  every  way,  provided  the  excess  of  ni- 
trogen he  had  been  taking  was  doing  him  harm.  One  must 
know  something"  of  the  chemical  composition  of  foods  to  lay  ' 
out  such  a  diet,  for  it  will  not  do  to  tell  a  patient  to  live  on 
milk  and  eggs  and  fish  and  all  manner  of  vegetables,  and  to 
avoid  only  red  meats  and  the  black  meat  of  poultry,  etc. 

Professor  W.  O.  Atwater  and  Charles  D.  Woods,  of  the 
Agricultural  Department  at  Washington,  have  given  us  some 
interesting  tables  of  the  percentage  of  protein,  fat.  etc..  in 
common  e^'er}--day  food-stuffs,  and  it  is  surprising  to  see  how 
nearly  what  some  consider  light  diet  approaches  to  heavy  ni- 
trogenous diet.  Roast  ribs  of  beef  contain  16.9  per  cent,  of 
protein  and  26.8  of  fat;  sirloin  steak  holds  18.3  protein  and 
20.2  of  fat;  beef  liver.  21.6  of  protein  and  5.4  only  of  fat; 
corned  beef,  15.3  protein  and  2;^.;^  of  fat;  beef  tongue,  21.5 
protein  and  23.2  of  fat;    loin  of  veal.  19.4  protein  and  10.4 

203 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

fat;  loin  of  lamb,  17.6  protein  and  28.3  fat;  leg  of  mutton, 
18.2  protein  and  18  fat;  loin  of  pork,  16.8  protein  and  30.3 
fat;  salt  ham,  15.5  protein  and  39.1  fat;  bacon,  10  protein 
and  67.2  fat;  pig's  feet,  16. i  protein  and  14.8  fat;  pork  sau- 
sage, 12.8  protein  and  45.4  fat.  Of  course,  sausage  may  con- 
tain protein  and  fat  just  as  the  maker  chooses  to  put  in  each 
ingredient.  Soups :  Bouillon,  2  protein  and  i  fat ;  con- 
somme, 2.5  protein,  no  fat;  mock-turtle,  5.2  protein  and  9 
fat;  chicken  soup,  3.6  protein  and  i  fat.  Roast  chicken,  22.8 
protein,  1.8  fat;  this  is  the  average  of  all  edible  parts;  white 
meat  would  contain  less  protein.  Tripe,  protein  13,  fat  16,  a 
good  morsel,  low  in  protein  but  quite  high  in  fat.  Sweet- 
breads, the  thymus  gland  of  the  calf,  protein  15.4,  fat  12.  i. 
Brains  of  the  calf  are  very  fatty  and  not  very  nutritious,  and 
contain  a  high  percentage  of  cholesterin.  The  liver  and  kid- 
neys of  the  calf  are  very  palatable  and  fairly  nutritious;  the 
former  contains  protein  16.6,  fat  7.4,  and  ash  1.3,  and  the 
latter  about  18  protein  and  5  fat.  All  pork,  as  a  rule,  is  indi- 
gestible on  account  of  too  much  fat  in  proportion  to  other 
matters.  Goose,  13  protein  and  49.9  fat;  turkey,  20.6  pro- 
tein and  22.9  fat;  quail,  21.8  protein  and  8  fat.  As  a  rule, 
all  game  is  high  in  protein. 

It  is  interesting  to  compare  fish  with  the  meats  and  to  see 
how  they  compare  in  percentage  of  protein,  particularly  with 
our  strong  foods,  such  as  roast  beef  and  mutton.  The  aver- 
age fish  diet  is  surely  not  the  light  diet  we  unthinkingly  are 
apt  to  take  it  to  be;  nevertheless  fish  is  a  safer  and  lighter 
diet  than  red  meats  and  such,  even  if  we  take  the  stronger 
fish  like  cod.  Fish  diet  does  not  load  the  blood  with  as  much 
waste  as  the  heavy  meats  do,  requiring  the  getting  of  more 
oxygen  by  exercise  to  eliminate  them  from  the  system.  Thus 
fish  diet  does  not  render  the  over-fed  man  dull  like  heavy 
meats,  nor  is  there  any  truth  in  the  common  belief  that  fish 
diet  is  the  best  brain-food  from  the  excess  of  phosphorus  it 
contains.  Black  fresh-water  bass,  20.4  protein  and  1.7  fat. 
These  proportions  are  all  from  the  edible  portions  alone,  and 
so  with  the  meats  we  have  been  speaking  of,  and  thus  give 

204 


FORTY    YiCARS    JN    THJ':    Ml':i)ICAL    I'KOI-IiSSION 

higher  percentages  than  though  all  parts  were  taken  in 
making  the  percentage.  Sea  bass,  18.8  protein  and  .5  fat; 
fresh  shad,  18.6  protein  and  9.5  fat;  shad  roe,  20.9  protein 
and  3.8  fat;  rock,  18.3  protein  and  2.8  fat;  bhie  fish,  19  pro- 
tein and  1.2  fat;  "salt  cod,  21.4  protein  and  .4  fat;  sheeps- 
head,  20.3  protein  and  6.7  fat;  fresh  cod,  15.8  protein  and  .4 
fat;  flounder,  13.9  protein  and  .6  fat;  haddock,  16.8  protein 
and  .3  fat;  hahbut,  fresh,  18.3  protein  and  5.2  fat;  smoked 
herring  are  well  up  in  nitrogen,  and  so  are  white  fiish ;  fresh 
mackerel,  18.2  protein  and  7.1  fat;  salt  mackerel  22  protein 
and  22.6  fat;  white  perch,  19. i  protein  and  4  fat;  pike,  18.6 
protein  and  .5  fat;  fresh  salmon,  19.9  protein  and  7.4  fat; 
salmon  trout,  18.2  protein  and  11.4  fat;  smelts  belong  to  the 
salmon  family,  and  have  a  little  less  protein  and  fat  than 
salmon ;  salt  sturgeon  and  caviare  are  very  high  in  protein, 
fresh  sturgeon  not  so  high;  weak  fish,  17.4  protein  and  2.4 
fat;  clams,  8.6  protein  and  i  fat;  lobster,  edible  portion, 
16.4  protein  and  1.8  fat;  oysters,  6.2  protein  and  1.2  fat; 
scallops,  14.8  protein  and  .1  fat;  shrimps  are  very  high  in 
protein;  terrapin  is  high  in  protein,  the  dressing  makes  it 
higher;  crabs,  edible  portion,  protein  16.6,  fat  2.  Average 
cow's  milk,  protein  3.3,  fat  4,  water  87,  carbohydrates  5,  salts 
.7;  cream,  protein  2.7,  fat  26.7,  water  66,  carbohydrates  2.8, 
salts  1.8;  skim-milk,  protein  3.4,  fat  .3.  water  90,  carbohy- 
drates 5.1,  salts  .7;  condensed  milk  evaporated  in  vacuo  to 
about  one- fourth  its  bulk,  water  30.5,  protein  8.2.  fat  7.1, 
carbohydrates  52.3,  ash  1.9,  carbohydrates  being  increased 
by  the  sugar  added ;  human  milk,  albuminous  matters  2.04, 
fat  2)-7^^  milk-sugar  6.95,  mineral  matter  .14,  water  87.11; 
buttermilk,  water  91,  protein  3,  fat  .3,  carbohydrates  4.8, 
ash  .7;  goat's  milk  is  stronger  in  sugar  and  fat  than  cow-'s 
milk.  Koumiss  is  a  useful  food,  and  very  light,  and  con- 
tains after  twenty-four  hours'  fermentation  about  18  alcohol, 
milk-sugar  15,  fat  20,  salts  4,  lactic  acid  5,  albumin  2t,,  car- 
bonic acid  7,  etc.  To  make  koumiss  from  cow's  milk,  take 
one  quart  of  new  milk,  one-third  compressed  yeast-cake  or 
dessertspoonful  fluid  yeast,  one  heaped  tablespoonful  pulver- 

205 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

ized  sugar;  mix  and  warm  this,  put  in  a  champagne  bottle, 
and  tie  cork  down.  Do  not  use  a  thin  bottle.  Ten  hours' 
standing  at  a  heat  of  90°  will  make  it.  A  pint  patent-stopper 
beer-bottle  is  a  proper  utensil  to  make  a  pint  in.  Keep  on 
ice  or  in  a  cold  place.  Ordinary  cheese,*  33.5  protein  and 
24.3  fat. 

The  following  complete  analysis  of  hens'  eggs  has  been 
compiled  at  my  request  by  the  Director  of  the  Delaware  Col- 
lege Agricultural  Experiment  Station :  A  hen's  egg  of  me- 
dium size  weighs  50  grammes,  the  shell  6  grammes,  the  yolk 
16  grammes,  the  white  28  grammes;  total,  50  grammes.  Of 
one  hundred  parts  of  the  edible  portion  of  the  egg,  36.3  parts 
equal  the  yolk,  63.7  parts  equal  the  white;  total,  100  parts. 
The  white  of  the  egg  consists  of  water  86  per  cent,  (protein), 
albumin  14  per  cent. ;  total,  100  per  cent.  The  yolk  consists 
of  water  53  per  cent,  (protein),  albumin  16  per  cent.,  fat  30 
per  cent.,  salts  i  per  cent. ;  total,  100.  The  Bulletin  of  the 
Agricultural  Department  at  Washington  makes  the  edible 
portion  of  the  whole  egg  14.9  per  cent,  albumin  on  the  basis 
of  the  whole  egg;  32  parts  in  100  represent  yolk,  56  parts  in 
100  represent  white;  of  the  32  parts  of  yolk,  16  per  cent.,  or 
5.12,  equal  albumin;  of  the  56  parts  of  white,  14  per  cent, 
or  7.84,  equal  albumin;  total,  12.96  albumin.  From  this  it 
will  be  seen  that  the  whole  egg  is  fairly  high  in  nitrogen  and 
the  yolk  has  considerable  fat.  The  yolk  is  fairly  low  in  nitro- 
gen, and  the  gouty  man  may  eat  it  moderately,  but  not  the 
whole  egg.  For  some  reason  some  persons  cannot  eat  eggs 
at  all,  and  with  the  sick  they  often  disagree.  During  intes- 
tinal digestion  sulphuretted  hydrogen  and  ammonia  are 
evolved,  and  an  intestinal  storm  ensues.  The  yolk  here  pro- 
duces the  disturbance. 

If  there  is  any  difference  in  the  nutritive  value  of  eggs  as 
to  color,  the  white  eggs  are  the  most  nutritious.  The  salts  of 
the  whites  are  chiefly  chlorides.  The  eggs  of  chickens,  tur- 
keys, ducks,  guineas,  and  geese  are  ntost  used  for  food.  The 
duck-  and  goose-eggs  have  most  fat;  the  eggs  of  the  plover 
are  said  to  be  the  most  delicate,  and  are  a  rare  treat.     Eggs 

206 


FORTY    YEARS    IN    THE    MICDICAL    PROFESSION 

are  most  coini)Ietely  dii^ested,  and  hence  are  very  nutritious 
as  to  their  weij^'ht,  and  make  a  well-balanced  ration  with  car- 
liohydratcs  alone.  The  yolk  is  rich  in  fats,  containing  olein, 
palmitin,  yellow  pigment,  and  lecithin.  It  also  contains  grape- 
sugar  in  very  small  amount,  phosphates,  iron  comp(junds, 
and  sulphur. 

Notwithstanding  the  general  belief  to  the  contrary,  experi- 
ment shows  five  minutes'  actual  boiling  to  be  the  proper  time 
to  boil  hens'  eggs  to  make  them  most  digestible.  A  ten- 
minute  boiling  is  better  than  three  minutes.  Fifteen  minutes 
makes  the  yolk  very  digestible.  As  to  the  shape  of  eggs, 
those  of  hens,  ducks,  geese,  crocodiles,  and  snakes  are  mostly 
oval ;  those  of  guineas  and  most  sea-fowls  are  pear-shaped ; 
those  of  ov\-ls  and  turtles  and  the  like  are  spherical.  Yellow 
or  lirown  colored  eggs  are  laid  by  the  dark  Brahmas,  part- 
ridge Cochins,  black  Langshans,  Wyandottes,  and  barred 
Plymouth  Rocks;  brown  Leghorns,  buff  Leghorns,  white 
Leghorns,  and  the  white  and  black  Minorcas  lay  the  white- 
shelled  eggs.  The  fresher  the  egg,  the  more  digestible  and 
more  palatable  it  is.  The  albumin  becomes  less  digestible  as 
time  passes.  The  odor  of  spoiled  eggs  comes  from  the  for- 
mation of  hydrogen  sulphide  from  the  sulphur  in  the  yolk. 
As  an  egg  becomes  old  it  gets  lighter  in  w^eight.  Look 
through  a  fresh  egg  towards  the  light,  and  it  is  homoge- 
neous. If  spoiled,  it  is  opaque  at  the  top,  owing  to  the  forma- 
tion of  an  air-space.  In  salt  and  water,  two  ounces  to  the 
pint,  a  good  egg  will  sink.  To  coddle  an  egg,  put  it  in  cold 
water  and  heat  it  up  to  167°  F.,  and  keep  it  there  until  the 
albumin  is  cooked  to  the  centre,  say  five  to  seven  minutes. 
The  wdiite  coagulates  at  163°,  and  the  yolk  at  167°.  A  cod- 
dled egg  is  never  boiled,  for  then  the  heat  must  reach  212^. 
At  fifteen  cents  per  dozen,  hens'  eggs  are  cheap  food.  At 
thirty  cents  per  dozen  they  are  expensive  food. 

The  special  cheeses  are  stronger  than  ordinary  cheeses. 
Butter  contains  3  protein  and  92  fat.  Of  course,  in  milk  and 
cream  there  is  some  little  carbohydrates.  Sugar  is  nearly 
pure  carbohydrates  with  a  little  water,  about  three  per  cent. 

207 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Boiled  unpared  white  potatoes  contain  2.'j  protein,  .2  fat,  and 
22.3  carbohydrates ;  white  potatoes  have  considerably  more 
protein  when  boiled  with  the  skins  on  than  when  boiled  with 
their  skins  off.  In  boiling  with  the  skins  off  the  Department 
of  Agriculture  at  Washington  finds  that  there  is  loss  of  or- 
ganic nutrients  and  mineral  salts.  The  potassium  compounds 
particularly  are  lost,  and  these  are  very  necessary  for  health. 
The  loss  is  suffered  by  the  abrasion  of  the  soft  parts  while 
cooking.  Here  nearly  three  per  cent,  of  the  carbohydrates 
and  four  per  cent,  of  the  available  flesh-forming  nitrogenous 
matter  are  lost.  Boil  them  with  the  skins  on,  and  there  is 
only  a  little  loss  of  non-albuminoid  nitrogenous  substances 
and  mineral  matter.  Let  the  young  and  strong  preserve  the 
skins  in  cooking.  Let  the  gouty  man  discard  them  and 
thus  reduce  his  nitrogen.  The  proper  way,  after  all,  to 
cook  all  potatoes  is  to  bake  them,  and  thus  better  break  up 
the  starch.  Unpared  boiled  white  potatoes  also  contain  73.7 
of  water.  In  these  analyses  the  ash  does  not  appear  to  vary 
greatly,  and  is  composed  of  the  potassium,  sodium,  calcium, 
and  magnesium  chlorides,  sulphates,  and  superphosphates. 
These  are  important  to  take  into  account,  and  in  such  dis- 
eases as  angina  pectoris,  where  the  hardening  and  deteriora- 
tion of  the  blood-vessels  is  to  be  taken  into  consideration,  we 
want  as  much  as  possible  to  eliminate  lime  and  such  constitu- 
ents from  the  diet. 

Wheat  flour  gives  protein  10.4,  fat  i,  carbohydrates  75.6, 
and  little  ash.  Macaroni  gives  about  the  same  as  wheat  flour, 
so  it  is  not  a  gluten  preparation  by  any  means.  Barley,  pro- 
tein 9.3,  fat  I,  carbohydrates  77.6,  about  the  same  as  wheat 
flour.  Buckwheat  flour  has  only  6.1  protein  and  77.2  carbo- 
hydrates. Corn-meal  has  8.9  protein,  2.2  fat,  75.1  carbo- 
hydrates, and  little  ash.  Corn  hominy,  about  the  same  as 
corn-meal.  Oatmeal,  protein  15.6,  very  high,  fat  7.3,  also 
high,  and  carbohydrates  68,  less  than  corn  and  wheat.  Boiled 
rice  has  only  5  protein,  .1  fat,  41.9  carbohydrates,  and  52.7 
water,  with  little  ash;  it  is  easily  digested,  and  if  not  eaten 
with  too  much  fat  is  not  very  fattening.     Rye  flour  is  less  in 

208 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

protein  than  wheat  Hour,  but  is  hij^her  in  fat  and  carbohy- 
drates. Tapioca  is  nearly  pure  starch.  Dry  beans  are  very 
strong  in  protein,  carbohydrates,  and  fat.  Fresh  hma  beans 
have  much  water,  and  only  7.1  protein  and  22  carbohydrates, 
not  much  stronger  than  white  potatoes.  Green  peas  have 
much  water,  and  only  3.6  protein  and  9.8  carbohydrates. 
Potato  chips  have  7.6  protein,  35.5  fat,  and  50.6  carbohy- 
drates, a  very  fattening  morsel.  Sweet  potatoes  have  i)rotein 
3.6,  fat  1.3,  carbohydrates  49.1,  ash  2;  these  excel  the  white 
potatoes  very  much  in  fattening  properties.  Fresh  radishes 
are  nearly  all  water  and  refuse;  so  is  rhubarb,  but  it  has 
oxalic  acid,  and  bears  watching.  Onions  are  chiefly  water 
and  a  small  percentage  of  carbohydrates,  mostly  sugar,  and 
so  are  parsnips.  Lettuce  is  mostly  water.  Okra  has  2  protein 
and  9.5  carbohydrates.  Egg-plant  is  mostly  water,  but  is 
generally  cooked  with  too  much  fat.  Celery  is  mostly  water 
with  I.I  ash,  where  its  virtue  lies.  Cauliflower  has  over  90 
water,  cabbage  about  the  same.  Artichokes  have  considera- 
ble carbohydrates.  Beets  have  over  90  water  and  little  pro- 
tein, but  considerable  carbohydrates  in  the  shape  of  sugar, 
depending  on  the  variety  of  the  beet.  Graham  wdieat  flour 
has  8.5  protein,  1.8  fat,  55.9  carbohydrates,  1.5  ash,  and  32.3 
w^ater.  The  average  fruit  of  the  market  has  water  16.9.  pro- 
tein 6.2,  fat  10.5,  carbohydrates  64.7,  ash  1.7. 

In  looking  over  this  list  it  is  interesting  to  note  how  nearly 
alike  they  run  in  nitrogen,  how  much  they  vary  in  fats,  and 
how  little  they  vary  in  ash.  Roast  beef  is  scarcely  as  strong 
as  sirloin  steak  in  protein,  but  excels  it  in  fat  as  usually  cut. 
Boiled  beef  is  much  less  in  protein  than  roast  beef,  and  loin 
of  lamb  is  also  low^er.  Pigs'  feet  are  a  delicacy,  and  rather 
low  comparatively  in  protein.  The  average  pork  sausage  is 
not  very  strong  in  protein,  but  has  too  much  fat.  Of  the 
soups,  consomme  is  the  weakest  and  mock-turtle  the  strong- 
est, and  therefore  the  least  desirable  where  nitrogenous  diet 
is  objectionable,  as  in  gout  and  such  troubles.  The  seeker 
after  light  diet  might  take  a  little  goose,  avoiding  as  much  as 
possible  the  fat,  whilst  he  will  find  turkey  and  chicken,  if  he 
14  209 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

eat  the  dark  meats,  a  little  strong  in  protein.  When  we  come 
to  fish,  we  find  them  disappointingly  high  in  protein.  Tell 
your  gouty  patient  to  take  a  fish  diet,  and  he  goes  unwittingly 
to  salmon.  He  gets  19.9  protein  and  7.4  fat.  He  might  as 
well  eat  roast  beef,  except  he  gets  less  of  the  salts  and  other 
strengthening  ingredients  of  the  beef.  Fresh  mackerel  are 
nearly  as  bad,  and  salt  mackerel  worse,  except  here  one  eats 
less  in  weight.  Smoked  herring  are  very  high  in  protein  and 
fat,  but  I  think  one  takes  so  little  of  it,  we  may  indulge  in  a 
little  of  the  flesh  and  roe  in  order  to  give  an  exquisite  flavor 
to  a  simple  breakfast  or  tea  of  stale  bread  and  butter.  Fresh 
herring  are  about  like  shad  in  protein  and  fat.  If  you  are 
gouty,  avoid  cod,  especially  salt  cod.  May  your  gouty  friend 
eat  of  codfish  and  potatoes?  Well,  Sunday  morning  only 
he  may  partake  sparingly  of  this  New  England  luxury,  pro- 
vided they  have  not  absorbed  too  much  grease  in  the  cooking. 
Flounders  are  among  the  lowest  in  protein  and  fat  of  all  the 
fish,  and  may  be  eaten  more  freely  where  we  wish  to  avoid 
too  much  nitrogen.  Smelts  are  a  delicacy  in  cold  weather ;  in 
fact,  are  one  of  the  few  fish  whose  flavor  is  not  affected  by 
freezing,  but  alas !  they  are  of  the  salmon  tribe,  and  are  very 
strong  food.  Lobsters  and  crabs  are  reprobated  by  some  au- 
thorities for  the  gouty,  but  why  I  know  not,  if  eaten  with 
plain  dressing  only,  as  they  are  not  over  14  to  16  protein  and 
very  little  fat.  Some  good  authorities  give  lobster  too  low 
in  protein.  It  is  surprising  how  high  in  protein  those  elegant 
fresh-water  fish,  the  white  perch,  and  black  fresh-water  bass 
are,  the  perch  giving  19.1  protein,  but  only  4  fat,  and  the  bass 
20.4  protein,  but  only  very  little  fat.  That  king  of  edible 
fish,  the  shad,  has  18.6  protein  and  9.5  fat,  quite  a  strong 
food,  but  we  must  allow  shad  now  and  again,  though  very 
sparingly.  The  roe  is  another  luxury,  but  is  very  strong  in 
nitrogen,  but  not  so  very  strong  in  fat. 

How  disappointing  all  this!  Everything  good  is  high  in 
nitrogen,  and  nitrogen  is  poison  to  so  many  of  the  good  and 
brave  in  this  world.    Where  shall  we  send  them  for  luxuries  ? 


FORTY    YEARS    IN    TIIK    MEDICAL    PROFESSION 

Well,  thank  God  for  g'iving-  us  the  oyster,  and  the  clam,  and 
milk.  The  oyster  has  only  6.2  protein  and  little  fat.  The 
clam  has  8.6  protein  and  i  fat.  Scallops  are  stronger,  having 
14.8  protein.  Now,  with  milk  and  oysters  and  clams,  a  few 
scallops  now  and  again,  a  little  consomme, — very  little,  for 
a  few  tablespoonfuls  of  soup  are  sufficient  as  a  prelude  to  a 
dinner  always, — milk  ad  libitum,  even  if  it  must  be  skimmed 
or  partly  skimmed  or  separated,  or  alkalized,  with  rice  and 
white  potatoes  as  vegetables,  surely  one  cannot  starve. 

White  potatoes  are,  I  think,  a  much-abused  vegetable. 
They  contain  comparatively  only  a  little  protein,  and,  if  well 
baked,  a  very  little,  and  only  a  little  over  20  carbohydrates, 
and  lots  of  water,  which  harms  no  one.  I  look  upon  them  as 
among  the  most  innocent  of  the  starchy  foods,  with  a  ten- 
dency to  increase  the  alkalinity  of  the  blood.  When  baked 
almost  to  a  crisp,  I  allow  them  now  and  again  to  diabetics, 
to  keep  them  in  even  humor,  and  never  see  cause  to  regret  it. 
Do  not  forget,  it  all  depends  on  the  cooking,  though.  No  one 
dieting  to  cut  down  weight  can  afford  to  eat  potato  chips  as 
usually  cooked ;  remember  that. 

For  the  day  laborer  oatmeal  is  a  generous  food,  but  for  the 
gouty  man  it  is  to  be  shunned.  Too  much  of  it  is  eaten  by 
those  leading  sedentary  lives,  especially  by  those  having  at- 
tained middle  age,  but  when  sugared  and  creamed,  oh,  what 
a  dose!  Oh,  my  liver! — except  for  the  young,  active,  and 
vigorous,  or  those  suffering  from  wasting  diseases,  and  often 
I  think  it  too  much  even  for  some  of  them.  Think  of  it: 
protein  15.6,  fat  7.3,  and  carbohydrates  68,  and  to  this  add 
more  fat  in  cream  and  more  carbohydrates  in  sugar.  As  to 
the  non-starchy  vegetables,  spinach,  asparagus,  tomatoes,  and 
the  like,  they  are  mostly  water,  with  very  little  protein  and 
little  carbohydrates,  and  fulfil  various  indications  in  diet. 
The  only  trouble  about  them  is,  most  of  them  have  considera- 
ble oxalic  acid,  which  is  not  desirable  in  renal  irritations. 
Be)'^ond  this,  they  undoubtedly  serve  a  good  purpose  in  the 
economy.     As  fruits  and  nuts  will  be  referred  to  at  length 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

farther  on,  I  will  not  stop  to  consider  them  now  as  an  article 
of  diet.  Green  corn  boiled  is  a  vegetable  much  used,  and 
deservedly  so.  To  those  who  need  a  food  low  in  proteids  it 
is  very  acceptable,  and  to  those  who  suffer  from  slowness  of 
the  bowels  it  is  a  great  help,  the  refuse  of  the  corn  helping 
here  very  much.  Green  corn  fresh  runs  about  thus :  water 
88.2,  protein  i.i,  fat  .4,  carbohydrates  9.2,  ash  i.i;  green 
corn  canned  has  water  75.7,  protein  2.8,  fat  1.3,  carbohy- 
drates 19.3,  ash  .9:  the  sugar  always  put  in  canned  corn  in- 
creases the  carbohydrates ;  there  is  also  the  antiferment,  prob- 
ably salicylic  acid. 

In  all  canned  vegetables  and  in  much  of  the  other  canned 
stuffs  will  be  found  some  antiferment,  most  probably  salicylic 
acid.  Whilst  probably  these  antiferments  do  no  great  harm 
directly  to  the  individual  consuming  such  foods,  they  doubt- 
less do  harm  in  the  end  to  those  who  eat  them  continuously, 
for  they  slow  digestion  and  in  other  ways  interfere  with  its 
normal  processes.  There  is  another  trouble  not  to  be  over- 
looked by  those  eating  canned  products, — the  danger  of  lead 
poisoning,  a  condition  which  entails  a  horrible  state  of  suf- 
fering and  broken  health.  In  properly  conducted  canning 
establishments  no  solder  should  ever  be  allowed  to  get  into 
the  can,  and  all  solder- joints  should  be  made  absolutely  on 
the  outside  of  the  seam  of  the  can,  and  no  low-grade  tin 
should  be  used  for  cans,  for  it  is  nearly  all  lead  and  iron,  and 
little  tin.  Canned  products  are  very  universall}'-  used,  not 
only  by  those  at  sea,  and  by  travellers  who  are  cut  off  from 
fresh  supplies,  but  hotels  and  boarding-houses  and  even  pri- 
vate families  use  them  almost  exclusively  as  being"  cheaper 
and  more  convenient,  in  the  very  midst  of  summer,  and  in 
the  heart  of  the  vegetable-producing  country.  I  believe  this 
practice  to  be  in  violation  of  good  sanitary  methods. 

Speaking  of  lead  poison,  I  believe  it  to  be  in  one  degree  or 
another  the  cause  of  a  great  deal  more  of  suffering  and  ill 
health,  not  to  mention  its  evident  tendency  to  increase  the 
evils  of  uric  acid  troubles,  with  all  that  this  implies,  than  is 


FORTY    YEARS    IN    Till-:    MEDICAL    PROFESSION 

usually  thought.  It  is  particularly  a  cause  in  the  water  sup- 
ply, and  the  increased  use  being  made  of  it  in  the  trades,  such 
as  in  packing  tobacco  and  like  matters.  Rubber  also,  it  is 
well  known,  contains  lead,  and  should  be  used  carefully  with 
that  in  view.  I  have  personally  met  with  some  interesting 
cases  where  the  diagnosis  was  very  obscure,  until  the  water 
supply  was  looked  into,  and  then  all  was  plain.  Watch  for 
lead  poison  in  doubtful  and  obscure  cases ;  it  is  easy  to  get 
tripped  up  on  it,  my  medical  friends. 

In  the  part  of  Delaware  where  I  reside  the  surface  water 
is  very  pure  and  free  particularly  from  lime,  and  hence  no 
insoluble  coating  is  formed  on  the  pipes,  as  in  limestone  dis- 
tricts, hence  lead  pipes  for  the  water  supply  almost  invariably 
cause  poisoning.  I  have  met  with  a  number  of  cases.  Insolu- 
ble compounds  of  lead  may  produce  poisoning  as  they  break 
up  and  disintegrate ;  even  when  insoluble  coatings  are  formed 
on  lead  water-pipe,  after  a  time  the  pipe  corrodes  and  disinte- 
grates by  age,  and  is  dangerous.  Fortunately  iron,  for  eco- 
nomical reasons,  is  taking  the  place  of  lead  in  furnishing  the 
water  supply,  and  thus  much  lead  is  being  eliminated  as  a 
menace  to  the  good  health  of  families  and  communities. 
There  is  one  thing  yet  that  should  be  stopped.  In  Philadel- 
phia, for  example,  I  notice  that  when  they  lay  new  mains  of 
iron,  the  connecting  pipe  leading  from  the  street  main  to  join 
the  pipe  leading  to  the  house  to  be  supplied,  say  one,  two,  or 
three  feet  in  length,  is  made  of  pure  lead.  This  should  not 
be.  x\s  this  pipe  gets  old  it  disintegrates,  and  notwithstand- 
ing it  is  covered  by  an  insoluble  coating  of  lime,  etc.,  which 
the  Schuylkill  water  furnishes,  these  disintegrated  portions 
become  a  menace  to  the  health  of  those  using  the  water. 
Every  State  should  pass  a  law  forbidding  the  use  of  lead 
water-pipes,  at  least,  under  any  and  all  conditions,  and  the 
use  of  lead  under  all  circumstances  where  it  may  become  a 
factor  for  harm  should  be  placed  under  most  thorough  super- 
vision, as  should  all  other  substances  which  may  cause  similar 
trouble. 

213 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Coffee,  so  universally  used  as  a  beverage  and  an  article  of 
diet,  cannot  be  passed  without  mention.  Haig  condemns  it 
for  the  lithsemic  individual,  but  condemns  tea  more.  Its  com- 
position is  given  as  follows :  Water,  1.15;  fat,  14.48;  crude 
fibre,  19.89;  ash,  4.75;  caffeine,  1.24;  albuminoids,  13.98; 
other  nitrogenous  matter,  45.09;  sugar,  gum,  and  dextrin, 
1.66.  This  is  the  analysis  of  the  coffee-bean;  of  course  the 
beans  vary  in  quality  and  strength.  In  excess  it  produces 
restlessness  and  tremulousness  in  man,  according  to  Horatio 
Wood  and  other  authorities,  but  these  troubles  are  rather 
spinal  than  cerebral.  In  proper  doses,  not  too  large,  caffeine 
stimulates  the  heart;  in  poisonous  doses,  overcomes  it.  It 
increases  arterial  pressure  independently  of  the  vasomotor 
centres,  according  to  Horatio  Wood,  so  altogether  it  may  do 
good  in  some  neurotic  conditions,  in  some  heart  affections, 
and  where  we  want  diuresis.  Where  we  wish  to  avoid  in- 
creased blood-pressure,  watch  it.  If  very  strong,  it  retards 
digestion  and  puts  away  sleep  from  weary  eyes.  Like  all 
others  of  its  kind,  it  has  many  good  uses,  and  may  be,  and 
doubtless  is,  subject  to  much  abuse  in  excessive  use. 

Tea  may  be  classed  with  coffee,  and  we  use  it  both  green 
and  black.  For  green  tea,  the  leaves  are  steamed  before  they 
are  rolled  and  dried,  also  green  tea  contains  more  astringent 
matter  than  black  tea.  Thompson  gives  this  analysis  of 
Kozai.  Green  tea:  Crude  protein,  37.43 ;  fibre,  10.06;  ash, 
4.92;  theine,  3.20;  tannin,  10.64;  total  nitrogen,  5.99. 
Black  tea:  Crude  protein,  38.90;  fibre,  10.07;  ^sh,  4.93; 
theine,  3.30;  tannin,  4.89;  total  nitrogen,  6.22.  If  theine  is 
identical  with  caffeine,  as  it  is  said  to  be,  then,  as  far  as  theine 
is  concerned,  tea  acts  like  coffee  on  the  system.  There  is  not 
much  difference  apparent,  and  authorities  differ  upon  which 
is  best  to  help  on  the  soldier  in  his  marches,  but  all  agree  that 
one  or  the  other  is  essential  to  get  the  best  results.  Tea,  if 
taken  in  excess,  retards  digestion  by  precipitating  the  diges- 
tive ferments,  just  as  coffee  does.  When  you  make  tea  do 
not  boil  it,  do  not  stew  it.    In  the  early  days  of  the  advent  of 

214 


FORTY    YI'lARS    IN    'I'lll';    Mi".I)ICAI.    I'l<OI''I<:SSION 

the  Japanese  to  the  outer  world,  from  the  members  of  the 
great  Japanese  Embassy  whieli  left  Japan  after  the  Perry  ex- 
pedition I  learned  to  make  tea.  Put,  say,  one  teaspoonful  of 
tea-leaf  for  each  half-pint  of  tea  you  want;  pour  on  this  boil- 
ing hot  water;  let  it  stand  tightly  covered  two  minutes,  then 
stir  it  thoroughly  with,  say,  six  to  eight  revolutions  to  the 
right  and  as  many  to  the  left,  using  spoon  or  chopsticks ;  the 
tea  is  then  at  its  best,  and  the  sooner  you  drink  it  the  better. 
You  get  little  tannin  and  none  of  the  disagreeable  bitter  ex- 
tractive matters  of  the  tea.  Boil  your  tea,  you  get  tannin, 
bitter  extractives,  and  altogether  an  indigestible,  unwhole- 
some dose.  Stew  it, — well,  don't  throw  it  to  your  pigs,  they 
won't  eat  it  or  drink  it,  and  the  pigs  are  right. 

Again,  we  have  cocoa  and  chocolate,  both  prepared  from 
the  cacao-beans,  which  come  from  the  tree,  TJieobroma  cacao. 
Theobromine  is  the  alkaloid  of  cocoa,  and  is  very  much  in 
every  way  like  caffeine  and  theine.  The  kernels  of  the  cocoa- 
beans  are,  when  ground,  called  cocoa  nibs.  Cocoa  is  made 
from  these,  and  starch,  or  sugar,  or  both,  are  added  in  the 
making.  A  German  analysis  is  as  follows :  Theobromine, 
1.73;  total  nitrogenous  matters,  19.88;  fat,  30.51;  water, 
3.83;  ash,  8.30;  fibre,  etc.,  37.48.  In  recommending  cocoa, 
remember  it  is  fattening  from  fat  and  sugar,  and  also  con- 
tains starch  usually.  Chocolate  is  made,  according  to  Thomp- 
son, from  the  husked,  dried,  ground,  and  fermented  cocoa- 
seeds,  which  are  then  roasted  and  made  into  paste.  Sugar  is 
added,  at  least  fifty  per  cent.,  and  various  flavorings.  Choco- 
late is  less  fatty  than  cocoa,  and  altogether  not  so  rich.  The 
husks  of  the  seeds  make  cocoa-shells,  and  a  decoction  of  these 
is  often  used  for  a  light  drink,  where  we  want  something  near 
to  water. 

Before  leaving  the  subject  of  coffee,  tea,  and  cocoa,  let  me 
enter  a  plea  for  their  close  study  by  the  physician  as  an  article 
of  diet  so  universally  used.  Whilst  they  may  be  abused  by 
the  masses  generally,  they  are  all  strong  weapons  in  the  hands 
of  the  profession   for  good.      Remember   their   stimulating 

215 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

properties,  their  comforting  properties,  and  the  habit  so  uni- 
versal with  our  patients.  Remember,  in  your  fever  cases,  in 
your  cases  with  wasting  disease,  you  will  often  find  in  these 
products  a  very  useful  ally.  Remember  that  because  people 
are  ill  is  by  no  means  a  reason  they  should  not  drink  tea  or 
cofifee.     Study  the  case  and  decide  it  properly. 

The  dietary  studies  made  by  Atwater  and  Woods  in  New 
York  City  in  1896  show  many  interesting  facts  for  the  phy- 
sician and  statesman.  They  show  in  a  glaring  manner  the 
average  want  of  thrift  among  the  plainer  people  and  the  utter 
ignorance,  especially  of  the  women,  of  the  value  of  one  food 
above  another,  of  the  kind  of  food  to  purchase,  looking  to  its 
food  value,  and  of  the  proper  method  of  preparing  it.  Our 
people  need  general  instruction  in  all  of  these  matters,  and  it 
should  commence  in  the  schools,  and  some  general  system 
should  be  devised  in  communities  to  teach  the  average  house- 
wife at  least  the  first  principles  of  food  values,  of  the  differ- 
ence between  a  food  that  will  furnish  fat  and  one  that  will 
furnish  muscle  and  endurance,  and  thus  give  her  some  insight 
how  to  dispose  of  her  money  to  the  best  advantage  when  she 
goes  to  purchase  her  supplies.  Atwater  and  Woods  show  the 
result  of  such  ignorance  very  plainly  as  they  progress  in  their 
studies.  Physicians  should  be  able  to  instruct  the  families 
they  attend  as  to  their  food  supply  and  the  nutrients  required 
by  different  families  to  keep  them  in  strength  and  good  health. 
A  family  where  most  of  the  members  are  laboring  men  and 
women  surely  requires  a  different  food  supply  from  the  fam- 
ily of  men  and  women  living  a  quiet  life  of  ease  and  comfort. 
Practically  no  thought  is  taken  of  this  either  by  families  or 
b}'-  physicians.  I  am  sure,  as  society  goes  on  to  the  evolution 
of  a  higher  civilization,  it  will  be  the  duty  and  the  every-day 
work  of  the  family  physician  to  take  charge  of  such  matters 
in  the  families  they  attend,  and  thus  lead  to  a  more  general 
rational  living,  and  to  better,  happier,  and  healthier  lives  for 
the  individual. 

The  lower  classes  of  Germans  and  French  at  home  have 

216 


FORTY    YI':/\RS    IN    Till".    MKDICAL    I'ROI' lOSSION 

more  of  thrift,  of  meth(^<lical  saving,  of  home  thrift,  than 
have  our  people.  The  paternal  governments  they  live  under 
and  their  habits  have  most  to  do  w^ith  this.  The  German 
lives  close  and  is  not  reckless  as  to  running  into  del)t  as  are 
our  people.  He  is  not  mean,  he  is  close  and  careful ;  most  of 
the  food  of  his  family  is  purchased  ready  to  eat.  He,  as  a 
rule,  keeps  no  fire  to  cook  by,  because  it  is  expensive.  When 
he  gets  too  cold  to  sit  up  he  goes  to  bed.  He  has  little  home 
life.  His  recreation  is  taken  at  the  beer-garden,  and  his  family 
goes  with  him.  His  native  thrift  follows  him  there.  He 
does  not  guzzle  beer,  nor  pay  for  it,  as  our  people  do.  for 
others  to  guzzle.  If  he  has  children  at  work,  they  get  up  in 
the  morning  and  eat  their  breakfast  cold,  probably  bread, 
sausage,  and  beer.  On  their  way  to  work  they  stop  and  buy 
their  dinner, — a  roll,  a  slice  of  meat  of  some  kind,  and  very 
little  of  it;  this,  with  a  glass  of  beer  from  a  near-by  shop, 
completes  their  dinner.  Their  supper  does  not  differ  from 
their  breakfast.  The  cost  of  living  per  individual  is  low,  very 
low^  It  is  their  life  custom,  and  they  keep  it  up.  Many  of 
the  Germans  are  dyspeptic  from  this  way  of  living,  and,  as  a 
rule,  too  much  beer  in  their  ration  keeps  it  up.  At  the  same 
time  this  ration  is  about  correct  as  to  its  protein,  carbohy- 
drates, and  fat,  and  serves  its  purpose  better  than  a  more 
elaborate  one  not  so  well  balanced. 

Our  people  are  dyspeptics  too.  not  because  they  are  frugal, 
but  because  they,  as  a  rule,  violate  every  law  of  gastronomic 
hygiene,  and  keep  at  it,  because  from  ignorance  and  want  of 
proper  teaching  they  know  no  better.  As  preventive  medi- 
cine asserts  itself  more  and  more,  and  becomes  more  and  more 
a  science,  the  physician  wdll  become  a  teacher  and  more  and 
more  the  confidential  friend  and  adviser  of  his  patients,  not 
more  during  the  illness  of  his  patients  than  during  their  good 
health,  and  thus  man  will  approach  nearer  and  nearer  the 
ideal  man  science  is  now  more  than  dreaming  of. 

To  return  to  Atwater  and  Woods.  They  give  the  result 
of  a  ten  days'  study  of  the  diet  of  a  family,  consisting  of 

•21/ 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

father,  a  mechanic,  mother,  and  three  girls,  one  eleven  years 
old,  one  eight  years,  and  one  eight  months.  The  family  was 
poor,  and  the  eleven-year-old  daughter  did  the  marketing, 
and,  of  course,  was  imposed  upon.  The  cost  of  the  food  pur- 
chased for  ten  days  was  $10.22,  very  high  for  their  means. 
The  rent  was  $12  per  month.  The  man  when  at  full  work 
made  $50  per  month.  Deducting  cost  of  food  and  rent  from 
this,  it  only  left  $7  per  month  for  fuel,  lights,  clothing,  and 
other  requirements.  By  proper  expenditure  for  proper  food, 
$15  to  $20  should  have  kept  this  family,  instead  of  $30  per 
month.  The  cost  of  the  animal  food  was  fifty-six  per  cent., 
and  of  the  vegetable  food  forty- four  per  cent.  •  Beef,  veal, 
mutton,  and  fish  composed  more  than  one-half  of  the  cost  of 
animal  food.  The  cost  of  the  vegetable  food  was  enhanced 
by  the  use  of  high-priced  self-raising  flours  and  the  like,  show- 
ing want  of  management  in  buying.  Bananas  and  oranges 
were  extravagances  for  them  to  indulge  in,  considering  their 
food  value,  being  mostly  water.  The  girl  bought  peanuts, 
and  thus  unconsciously  made  a  good  bargain.  You  get  much 
protein  for  a  small  price  here,  and  also  much  fat  and  carbo- 
hydrates. For  this  family  the  food  purchased  per  man  per 
day  furnished  one-fourth  more  nutriment  than  is  needed  for 
a  man  at  moderate  work.  Three  per  cent,  of  the  total  food 
was  thrown  away  in  the  table  and  kitchen  waste,  and  thus 
one  per  cent,  per  man  per  day  of  protein  was  wasted.  De- 
ducting this,  and  there  was  still  an  excess  of  food.  The  food 
eaten  contained  at  least  25  grammes  of  protein  and  a  fuel 
value  of  600  calories  per  man  per  day  more  than  was  needed 
by  a  man  at  moderate  work.  When  the  man  was  out  of 
work  he  and  his  family  would  have  been  well  nourished  if 
the  food  had  only  contained  100  grammes  of  protein,  and  had 
a  fuel  value  of  3000  calories  per  man  per  day.  The  nutritive 
ration  of  the  food  eaten  (i  :  5.5)  was  about  equal  to  the 
dietary  standards.  In  this  case  Atwater  and  Woods  suggest 
that  the  amount  of  food  purchased  might  have  been  reduced 
twenty-five  to  thirty  per  cent,  and  a  considerable  saving  of 

218 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

money  effected.  A  more  judicious  selection  of  food  and 
greater  attention  to  details  of  marketinj^  and  preparation  of 
the  food  might  have  still  further  reduced  the  cost.  Such 
carefulness  in  purchase  and  preparation  would  also  have  re- 
duced the  kitchen  and  table  wastes,  so  that  practically  no  food 
would  have  been  wasted.  The  more  intelligent  selection  of 
food,  from  both  the  nutritive  and  pecuniary  stand-points, 
would  preclude  the  purchase  at  the  prices  paid  of  such  foods 
as  chicken,  cod,  flounder,  shad,  condensed  milk,  canned  as- 
paragus, prepared  flours,  radishes,  celery,  cherry  jelly,  etc., 
which  this  inexperienced  little  market-girl  bought,  and  would 
lead  to  the  increased  purchase  of  more  economical  foods,  in- 
cluding peas,  beans,  wheat  flour,  rice,  and  the  cheap  but  nutri- 
tious cuts  of  beef,  veal,  and  mutton.  In  this  way  a  large 
proportion  of  the  money  spent  for  food  could  have  been  saved 
with  advantage  to  health  and  without  interfering  with  the 
palatability  of  the  food  eaten. 

All  this  is  interesting  and  quoted  here  to  show  in  what  a 
slipshod  manner  such  people  live.  Surely  the  physician  must 
be  one  great  factor  in  bringing  about  a  better  system,  and 
should  surely  study  all  of  these  great  economic  questions.  In 
another  case,  to  show  injudicious  division  and  expenditure  of 
an  allowance  of  money,  they  give  a  family  w-here  it  seemed 
hopeless  to  attempt  to  express  in  terms  of  protein  and  fuel 
value  wdiat  was  needed  for  their  better  nutrition.  The  house- 
keeping needed  absolute  revolution.  With  such  carelessness 
on  all  sides  it  is  almost  useless  to  suggest  improvements  in 
the  kinds  and  amounts  of  foods  to  be  purchased.  The  dietary 
needed  more  protein,  and  a  much  smaller  expenditure  for 
butter  would  allow  this  family  to  procure  it.  They  spent 
about  as  much  for  butter,  fish,  and  chicken  as  for  beef  and 
pork,  the  amount  spent  for  beef  and  pork  being  $3.57,  and 
for  butter,  fish,  and  chickens,  $3.48.  The  former  furnished 
1645  grammes  of  protein  and  41,950  calories;  the  latter,  743 
grammes  of  protein  and  35,700  calories.  This  case  shows 
the  necessity  for  judicious  buying  and  selecting  to  get  the 

219 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

best  results  for  health  and  strength,  and  physicians  cannot 
know  too  much  about  it;  patients  and  the  people  generally 
surely  know  too  little. 

Great  advances  have  been  made  in  feeding  the  lower  ani- 
mals both  for  milk  and  meats  by  working  up  and  studying 
and  feeding  a  balanced  ration.  How  much  more  is  it  neces- 
sary to  work  up  and  study  and  prepare  for  man  a  balanced 
ration !  We  would  get  all  the  required  nourishment  for  man 
from  pork,  stale  bread,  olives,  milk,  and  cheese,  but  it  would 
not  be  a  good  combination  for  easy  digestion,  because  there 
are  too  many  articles  here  of  slow  digestion.  A  man  doing 
hard  work  would  enjoy  life  more  and  thrive  better  on  pork, 
beans,  and  corn-bread  than  he  would  on  a  steady  diet  of  even 
a  balanced  ration  like  corn-bread,  milk,  oysters,  and  rice,  for 
the  latter  would  not  last  long  enough  in  digestion,  and  leave 
the  organs  too  long  inactive  between  meals.  Oatmeal,  bread, 
and  milk  would  do  better,  especially  should  some  sugar  be 
added.  The  balanced  ration  is  the  important  matter  for  man. 
A  man  who  does  not  eat  enough  often  gets  an  unbalanced  ra- 
tion and  does  not  thrive ;  so  does  the  man  who  eats  too  much. 
Pork,  butter,  and  eggs  would  be  an  unbalanced  ration, — too 
much  fat  and  too  little  carbohydrates.  A  man  cannot  live  on 
potatoes  alone  and  thrive;  it  would  take  a  peck  of  potatoes 
daily  to  give  him  enough  protein. 

Again,  let  me  give  the  estimated  food  necessary  for  man 
for  twenty- four  hours.  A  work  ration:  Protein,  125 
grammes;  fat,  125  grammes;  carbohydrates,  450  grammes; 
calories,  3500,  with  salts,  30  grammes.  A  mere  subsistence 
ration  would  be  as  follows :  Protein,  75  grammes  per  day ; 
fat,  40  grammes;  carbohydrates,  325  grammes;  calories, 
2000,  with  salts,  25  grammes.  An  ideal  ration  (Mrs.  Rich- 
ards) would  be,  for  twenty- four  hours:  Wheat  bread,  16 
ounces ;  beef,  8  ounces ;  oysters,  8  ounces ;  cocoa,  i  ounce ; 
cow's  milk,  4  ounces ;  broth,  16  ounces;  sugar,  i  ounce;  but- 
ter, y^  ounce.  This  for  a  man  doing  average  work,  and 
would  furnish  2575.52  calories.  So  far  as  we  know,  basing 
our  ideas  on  chemistry  and  physiology,  so  far  as  developed, 

220 


FORTY    VICARS    IN    Till'.    MEDICAL    I'KOI-KSSION 

we  arc  riji^ht  in  tlic  views  of  diet  here  taken.  We  have  ^onc 
upon  tlie  theory  that  the  nitrogenous  or  albuminous  princi- 
ples, after  undergoing  complete  combustion,  end  in  urea,  and 
incomplete  combustion,  end  in  uric  acid,  and  are  unfit  diet  for 
diseases  caused  by  excess  of  urea  and  of  uric  acid,  whether 
the  cause  be  from  damaged  machinery  of  the  body,  or  from  a 
peculiar  diathesis.  These  nitrogenous  foods,  comprising 
butcher's  meats,  poultry,  fish,  shell-fish,  eggs,  and  milk,  not 
forgetting  the  vegetable  albuminoids,  as  the  coverings  of  the 
starch  granules  of  grains,  etc.,  are  the  tissue-builders  or  flesh- 
formers.  Now,  although  we  are  so  sure  of  this  and  so  sure 
we  are  right,  yet  there  are  those,  and  men  of  reputation,  who 
deny  such  conclusions  as  regards  diet  for  the  so-called  uric 
acid  conditions,  and  advocate  the  exclusion  of  the  carbohy- 
drates rather  than  the  nitrogenous  group.  All  we  can  say  to 
such  criticism  is,  w^e  believe  we  are  right,  yet  we  wall  strive 
to  learn  more,  even  to  the  rewriting,  if  necessary,  of  ever- 
changing  uric  acid  literature;  but  we  shall  not  despair,  for 
there  are  those  living  who  deny  the  virtue  of  diphtheria  anti- 
toxin or  the  protection  from  small-pox  by  vaccination.  We 
have  also  gone  upon  the  theory  that  the  non-nitrogenous 
foods,  all  the  vegetables,  fruits,  cereals,  starches,  sugars, 
gums,  fats,  and  oils,  being  both  animal  and  vegetable,  and 
the  organic  acids,  are  the  maintainers  of  animal  heat  and 
the  force-producers.  As  before  mentioned,  these  are  also 
tissue-builders  in  a  small  degree  from  the  vegetable  albumi- 
noids they  contain.  We  have  also  recognized  as  fact,  that 
certain  salts  also  are  taken  from  the  foods  eaten,  the  least  from 
fruits  and  nuts,  next  from  meats,  and  most  of  all  from  vege- 
tables, these  salts  being  for  the  most  part  chloride  of  sodium, 
potassium  chloride,  sodium  carbonate,  potassium  carbonate, 
potassium  sulphate,  sodium  sulphate,  magnesium  sulphate,  cal- 
cium phosphate,  sodium  phosphate,  potassium  phosphate,  and 
others,  these  going  to  various  uses  in  the  economy,  such  as 
regulating  the  specific  gravity  of  the  blood,  checking  putrefac- 
tion of  tissues,  controlling  osmosis,  etc. 

Vcgctariainsiii. — It  has  been  pretty  well  established  that 


FORTY    YEARS    IX    THE    MEDICAL    PROFESSION 

man  cannot  live  in  health  and  comfort  and  enjoy  life  on  a 
vegetable  diet  alone.  As  before  stated,  it  would  take  a  peck 
of  white  potatoes  a  day  to  give  a  man  sufficient  protein  for 
laborious  work.  He  may  get  everything  from  vegetables, 
but  not  sufficient  for  a  balanced  ration  from  a  reasonable 
amount  of  food.  Vegetarians  are  usually  fanatics,  non-pro- 
ducers, but,  as  a  rule,  take  great  care  of  their  health  and  do 
not  dissipate,  commendable  qualities,  and  if  they  would  only 
live  on  a  scientific,  well-balanced  ration,  they  would,  as  a  rule, 
live  longer,  be  happier,  and  be  more  useful  citizens.  Those 
who  live  only  on  vegetable  food,  and  on  that  food  which  de- 
stroys no  life  to  get  it,  such  as  eggs  and  milk,  can  get  a  well- 
balanced  ration,  and  surely  will  be  better  and  happier  than 
those  who  take  an  omnivorous  diet  unscientifically  chosen  in 
quantity  and  quality  and  ravenously  eaten.  We  cannot  argue 
that  the  ancient  Britons  subsisted  on  roots  and  nuts  and  the 
spontaneous  productions  of  the  ground,  or  that  certain  savage 
tribes  live  on  vegetables  alone.  Providence  provided  and  does 
provide  a  complete  ration  for  them  in  some  way  and  at  some 
time,  if  not  regularly,  or  they  would  never  be  the  sturdy 
races  they  were  and  are. 

Special  Diets  for  Corpulency,  and  how  to  get  Fat  when  too 
Lean. — All  of  these  special  diets,  or  special  systems,  or  fads, 
or  whatever  you  may  call  them,  mean  starvation  in  a  greater 
or  less  degree.  Withhold  a  proper  amount  of  food  from  the 
animal,  and  you  cause  loss  of  weight.  Excessive  weight  is  a 
great  source  of  inconvenience, — a  humiliation  to  some.  It  is 
most  frequently  hereditary  and  a  perfectly  natural  state  for 
the  individual.  After  all,  the  philosophy  of  existence,  in  one 
sense  at  least,  is  to  feel  good  and  well.  Obesity  may  be  a 
disease,  but  if  so,  it  is  usually  the  fault  of  bad  habits  in  the 
individual.  If  one  will  live  a  sober,  industrious,  and  in  every 
way  a  temperate  life,  restricting,  as  one  surely  must  very  de- 
cidedly, the  appetite  for  sugars, -starches,  and  fats  in  particu- 
lar, and  for  all  meats  and  drinks  somewhat,  but  not  beyond 
the  comforts  of  existence,  as  most  of  these  special  methods 
do,  then  one  will  neither  be  overburdened  with  fat  nor  threat- 


FORTY    YI^ARS    JN    TILI'     MICIJICAI.    PROFESSION 

encd  with  evils  of  a  more  (laiij:^eroiis  kind  from  unscientific 
regimen. 

The  Banting  system  undoubtedly,  if  followed  up.  causes 
loss  of  bulk,  but  has  its  dangers,  and  surely  is  most  inconve- 
nient and  unpleasant  to  those  following  it.  He  allowed  about 
twelve  ounces  of  lean  meat  per  day,  about  two  ounces  of 
bread,  and  about  twelve  ounces  of  fruit  and  green  vegetables. 
He  allowed  thirty-five  ounces  of  fluids  in  twenty-four  hours, 
nothing  like  as  much  fluid  as  a  man  should  part  with  in  the 
same  length  of  time.  As  Thompson  says,  the  fats  and  albu- 
minoids are  not  well  balanced  here,  and"  constipation  of  the 
bowels  must  ensue. 

The  Ebstein  system,  as  given  by  Thompson,  is,  that  ani- 
mal food,  as  well  as  carbohydrates,  particularly  sugars  and 
starches,  are  capable  of  being  turned  into  fat.  The  carbohy- 
drates, he  says,  furnish  force  for  the  body,  and  by  their  com- 
bustion spare  the  complete  oxidation  of  the  albuminates,  which 
are  therefore  stored  in  the  tissues  in  a  suboxidized  form.  His 
theory  is  that  fatty  food  does  not  give  rise  to  the  storage  of 
fat  in  the  body,  and  he  allows  it,  and  particularly  because  it 
causes  satiety  sooner  and  makes  one  eat  less.  He  allows  no 
sugar,  potatoes,  rice,  or  other  farinaceous  food  except  three 
ounces  and  a  half  of  bread  daily.  He  allows  the  non-starchy 
vegetables  and  a  moderate  amount  of  any  kind  of  meat.  He 
restricts  fluids  to  about  one-half  normal.  Breakfast,  one  cup 
of  black  tea,  no  sugar  or  milk,  with  two  ounces  of  buttered 
toast.  Dinner,  at  noon,  six  ounces  of  boiled  or  roasted  fat 
beef,  W'ith  drip  gravy,  one  or  two  non-starchy  vegetables  in 
moderation,  and  for  dessert  a  salad  and  fruit,  a  little  light 
wine,  and  tea,  no  sugar  or  milk.  Supper,  tea.  no  milk  or 
sugar,  one  soft  egg.  a  moderate  allowance  of  fish.  ham.  or 
cold  fat  meat,  one  ounce  thin  buttered  bread  or  toast,  and 
fruit.  On  this  diet  one  cannot  work  hard  or  take  active  exer- 
cise and  be  thoroughly  comfortable,  for  he  only  gets  fourteen 
»  hundred  calories  potential  energy  in  nutrients. 

Here  is  a  table  b}"  Atkinson  of  a  comparison  of  dietaries 
for  corpulence,  with  ordinary  dietaries,  from  Thompson : 

223 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 


I'lETARlES. 


Banting  system 

Ebstein  system 

Playfair's  standard  for  subsist- 
ence diet 

Voit's  standard  for  laboring 
man  at  moderate  work  .    .    . 

Playfair's  standard  for  adults 
with  moderate  exercise  .    .    . 

Atkinson's  standard  for  a  man 
with  light  exercise 

Atkinson' s  standard  for  a  labor- 
ing man  at  moderate  work    . 

Poor  sewing  girl,  London,  diet 
barely  sufficient  for  subsist- 
ence      

University  professor,  Germany, 
very  little  exercise 

Well-to-do  family,  Connecticut, 
food  actually  eaten     .... 

Mechanics  and  factory  opera- 
tives, Massachusetts,  food 
purchased 

Food  actually  eaten  by  college 
students — 

From  Northern  United  States    . 

From  Eastern  United  States  .    . 


Nutrients. 


Protein. 


Gramvtes. 
171 
102 

57 
118 
119 


125 


53 


128 


127 


104 


Fat. 


Grammes. 

8 

85 

14 
56 
51 

I(X) 

125 

2,3. 
100 
177 


136 


Carbohy- 
drates. 

Total. 

Grammes. 

Grammes. 

75 

254 

47 

234 

341 

412 

500 

674 

531 

701 

360 

560 

450 

700 

316 

402 

240 

440 

466 

771 

531 

844 

622 

944 

421 

661 

Potential 
Energy  in 
Nutrients. 


Calories, 
1085 
1400 

1760 

3050 

3140 

2815 

3520 

1820 

2325 
4080 

4430 


4825 
3415 


From  this  table,  the  patients  under  Banting  and  Ebstein  get 
starvation  diet  sure.  Whilst  the  student  from  the  Eastern 
United  States  gets  too  much,  Atkinson's  man  at  moderate 
work  gets  well  supported,  the  poor  sewing-girl  is  ill  nour- 
ished, mostly  on  carbohydrates,  as  we  should  suppose,  and 
the  German  professor,  how  about  him?  Well,  he  does  not 
live  high,  but  gets  several  glasses  of  beer,  as  his  carbohydrates 
show. 

The  QErtel  system  is  a  newer  system,  and  I  am  indebted  to 
Professor  Thompson's  book  for  information  in  regard  to  it. 

224 


FORTY    YEARS    TN    TTTK    MEDICAT.    PROFESSION 

The  feature  in  (JCrlel's  system  is  to  strengthen  the  circulation 
by  strent^theninj:^  the  heart,  and  then  the  fat,  once  j^fjtten  rid 
of,  does  not  return.  He  makes  two  classes  of  the  obese,  and 
regulates  their  diet  accordingly :  First,  those  in  whom  fat  has 
accumulated,  but  in  whom  the  circulation  and  respiration  are 
not  impaired  and  the  person  can  use  muscular  effort  and  walk 
or  run.  Second,  those  in  whom,  from  advanced  stasis  and 
hydrcTmia,  and  with  a  deficiency  of  h?emoglol)in  in  the  blood, 
ansemic,  the  amount  of  oxygen  taken  up  from  the  lungs  is 
much  reduced,  and  who  are  short  of  breath  on  exertion.  For 
the  first  class  he  allows  50  grammes  of  fat,  carbohydrates  200 
grammes,  with  150  grammes  albumin,  or  more,  if  needed. 
For  the  second  class — fat  people,  short-winded,  and  with 
dropsical  tendencies,  I  suppose,  he  mostly  puts  in  this  class, 
yet  with  organs  fairly  sound — he  allows  30  grammes  of 
fat  daily,  with  100  grammes  carbohydrates,  and  considerably 
over  150  grammes  albumin,  more,  you  see,  than  the  first  class 
gets.  In  this  second  class  he  gives  little  fluid,  and  not  over- 
much to  the  first  class.  He  thus,  he  says,  reduces  blood- 
pressure,  venous  stasis  is  lessened,  and  thus  the  vessels  in  the 
fatty  tissue  are  drained,  and  nutritive  changes  occur  here,  the 
fat  is  broken  up,  carried  away,  and  cremated,  as  it  were. 
CErtel  allows  twice  the  amount  of  animal  food  that  Ebstein 
allows,  double  the  amount  of  carbohydrates,  and  less  than 
half  the  fat.  He  also  allows  more  fat  and  starch  than  Bant- 
ing. He  allows  twelve  ounces  light  wine,  and  as  much  water 
at  dinner,  a  very  fair  allowance,  with  six  ounces  of  bread 
daily.  He  allows  eggs  now  and  again.  For  those  who  are 
able  he  prescribes  the  "  terrain  cure,"  mountain  climbing, 
watching  the  heart,  which  gets  strength  as  the  exercise  pro- 
gresses. For  those  who  cannot  climb  or  use  exercise,  he 
prescribes  massage,  friction,  and  baths,  here  still  further  re- 
ducing fats  and  starches. 

The  Schweninger  system  is  about  like  QErters.  but  he  al- 
lows no  drink  at  meals,  but  must  wait  until  two  hours  after 
meals  to  drink.  He  gives  little  bread,  and  restricts  fluids  gen- 
erally. 

IS  225 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Germain-See  says  much  water  is  necessary  in  treating  cor- 
pulency. He  allows  meats,  lean  and  fat,  but  no  sugar  or 
starches.  His  drinks  are  hot,  weak  tea  and  an  abundance  of 
water.  He  allows  little  or  no  alcohol.  Thompson  suggests 
this  treatment  with  plenty  of  fluids  is  best  for  gouty  and 
rheumatic  cases  where  we  desire  to  eliminate  the  waste  from 
the  system.  This,  at  any  rate,  is  some  encouragement  to  the 
gouty,  stout  man,  who  so  far  has  received  little  consideration 
in  this  matter. 

S.  Weir  Mitcheirs  system  for  obesity  consists  chiefly  in 
rest,  skim-milk  diet,  massage,  and  movements  for  passive 
exercise.  After  a  fortnight  he  begins  to  allow  a  little  light 
broth ;  he  is  careful  to  watch  the  condition  of  the  heart ;  after 
six  weeks  he  allows  some  lean  meats.  This  treatment  re- 
quires the  abandonment  of  all  labor,  and  is  among  the  best  of 
treatments  to  amuse  whilst  at  the  same  time  it  relieves,  and  is 
especially  applicable  to  women  society-tired  and  suffering 
from  over-indulgence  in  various  forms. 

There  are  a  number  of  other  treatments,  named  for  the  men 
first  recommending  them,  but  they  differ  only  in  degree  from 
those  already  mentioned.  The  principle  in  all  is  the  same, — 
semi-starvation, — and  the  end  aimed  at  the  same, — viz.,  to 
cause  those  undergoing  the  treatment  to  oxidize  and  elimi- 
nate the  accumulated  fat  and  to  prevent  its  forming  again. 
There  are  many  quack  remedies,  under  various  names ;  all  are 
harmful  and  even  dangerous,  with  just  knavery  enough  in 
the  recommendations  accompanying  them,  putting  those  using 
them  on  a  diet  which  avoids  fat,  starches,  and  sugars,  to  give 
them  a  semblance  of  doing  effective  work  in  reducing  flesh. 
There  is  at  present  quite  a  fad  going  around,  especially  among 
women  fond  of  society,  taking  upon  themselves  some  cure  for 
obesity.  This  is  all  wrong,  unless  they  have  intelligent  medi- 
cal supervision,  and  this  intelligent  medical  supervision  should 
see  to  it  that  the  heart  and  kidneys  of  these  patients  are  thor- 
oughly observed  and  looked  after ;  withholding  fluids  in  these 
cases  is  often  attended  with  serious  consequences.  Renal  cal- 
culi may  supervene,  or  gall-stones  may  form  and  great  suffer- 

226 


FORTY    YEARS    IN    '11 1 1'.    MI'DICAI,    PROF  F.SSJON 

iiig"  ensue,  all  because  the  elimination  of  waste  has  been  inter- 
fered with.  1  once  knew  a  f^entleman,  a  n>yal  gof>d  fellow, 
of  middle  age,  who,  being  stont  and,  liaving  a  lung  capacity 
below  the  average,  did  not  oxidize  his  fat  fully  by  throwing 
it  off  from  his  lungs  in  the  shape  of  carbonic  acid  and  water. 
Hearing  from  some  wise  man  that  a  dose  of  Epsom  salt  every 
morning  in  a  small  portion  of  water  wcnild  make  him  thin,  he 
took  it  faithfully  for  several  months.  The  consequences  were 
disastrous.  This  man  had  a  strong  appetite;  in  fact,  he  ate 
meat  like  a  bloodhound,  starch  like  an  ox,  and  fat  like  an 
Esquimau,  and  the  more  salts  he  took  the  more  he  ate.  All 
of  his  fluids  ran  ofT,  normal  metabolism  was  interfered  with, 
the  composition  of  the  blood  was  altered,  the  elimination  of 
waste  was  interfered  with,  and  of  course  the  result,  renal  cal- 
culi, one  after  another,  stone  in  the  bladder,  and  prolonged 
suffering.  Nature  resents  such  unwarranted  interference  with 
her  laws.  My  own  idea  in  these  cases  is,  above  all  things,  to 
sttidy  the  individual,  then  arrange  the  diet,  exercise,  and  the 
habits  of  life  generall3^  Watch  particularly  the  condition  of 
the  heart,  the  general  circulation,  and  the  kidneys.  Age  is 
very  important  to  take  into  consideration,  and  so  is  sex  and 
the  environment  of  the  patient.  The  gouty  patient  needs 
different  advice  from  one  not  so  afflicted,  and  so  does  the 
patient  with  dropsical  tendencies.  Explain  to  each  what  their 
case  needs.  Explain  the  difference  in  the  make-up  of  foods, 
as  to  oxygen,  hydrogen,  carbon,  and  nitrogen,  and  the  differ- 
ence between  proteids  and  starches,  sugars  and  the  like,  and 
fats,  and  the  tendency  of  each  in  diet.  Intelligent  advice  and 
supervision  are  what  these  people  want.  Notice  the  superb 
condition  generally  of  the  athletes  of  the  University  of  Penn- 
sylvania. How^  is  it  their  condition,  their  fitness,  excel  ?  The 
answer  is  evident.  It  is  the  intelligent  supervision  and  direc- 
tion of  strong  and  able  men  like  Dr.  J.  William  White,  as- 
sisted by  such  experts  in  diet  and  other  accessories  as  Dr. 
Horatio  C.  Wood  and  others,  which  bring  this  about.  This 
earnest,  intelligent  supervision  is  one  of  the  great  factors  of 
success  in  mnch  that  pertains  to  life. 

2_V 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Leanness,  the  opposite  of  fatness,  afflicts  some  persons,  and 
is  often  so  extreme  as  to  cause  humiliation.  The  remedy  is 
to  find  out  the  cause,  and  remove  it  if  possible.  As  to  diet, 
reverse  the  principles  applied  to  obesity.  Lean  people  are  gen- 
erally perversely  lean,  and  will  not  get  fat,  even  when  in  per- 
fect health.  Plenty  of  proper  meat  and  drink,  avoiding  ex- 
cesses, rational  employment,  sound  sleep,  a  clear  conscience, 
and  proper  medical  supervision  is  a  good  recommendation  to 
such  people. 

Woman  without  a  StouiacJi! — What  shall  we  say  of  the 
woman  without  a  stomach,  now  living  in  Switzerland,  and 
possibly  of  others  in  Europe  and  in  this  country?  This  case 
of  Dr.  Schlatter's  in  Zurich  is  remarkable.  The  entire  stom- 
ach was  removed,  and  she  is  enjoying  good  health  and  even 
gets  sick  at  the  stomach  (?)  if,  perchance,  something  does 
not  agree.  How  paradoxical !  From  the  start  this  woman 
was  fed  on  soup,  oatmeal,  brandy,  and  wine,  and  these  were 
digested.  A  month  after  the  operation  she  became  nauseated 
and  vomited ;  in  the  vomit  bile  was  found,  which  is  against 
medical  theory.  Here  the  entire  theory  of  stomach  digestion 
is  made  to  totter.  These  internal  functions  must  be  restudied, 
and  this  part  of  physiology  must  be  rewritten.  We  know  the 
intestines  do  a  great  deal  of  the  work  of  digestion  and  assimi- 
lation, but  we  did  not  know  before,  nor  did  we  believe,  com- 
plete digestion  and  complete  assimilation  would  go  on  with- 
out a  stomach.  A  new  motto  has  been  generated.  What  is 
woman  without  a  stomach?    Much. 

Whilst  speaking  of  diet  for  obesity,  it  may  be  well  to  refer 
here  to  the  best  form  of  bread,  "  the  staff  of  life,"  without 
which,  in  some  form,  it  is  almost  impossible,  for  civilized 
man,  at  least,  to  exist.  The  best  form  of  bread  is  the  bread 
of  wheat,  white  bread,  as  distinguished  from  rye  bread  or 
graham  bread.  The  white  bread  contains  the  least  carbohy- 
drates naturally,  even  if  it  has  a  little  more  fat.  There  is  a 
rage  now  among  well-informed  people,  especially  among 
ladies  endeavoring  to  reduce  their  avoirdupois,  for  over- 
toasted  bread,  the  twice-baked  bread,  it  is  familiarly  called, 

228 


FORTY    YFCARS    IN    'I'lll':    MICDICAL    PROFKSSION 

which  fcally  appi'oachcs  very  near  to  the  well-kiKJwn  German 
"  zwcihack."  'Hiis  twice-hakcd  hrcad  is  quite  palatahle  and 
quite  nutritious,  and  if  eaten  in  moderate  quantity,  one  may 
a])pease  the  a])petite  for  bread  and  find  it  much  less  fattening 
than  ordinary  bread,  and  very  much  less  likely  to  cause  fer- 
mentation durinj*-  digestion.  To  prepare  this  twice-baked 
bread,  cut  from  the  loaf  (at  least  twenty-four  hours  baked) 
thin  slices,  place  them  in  a  pan,  and  subject  them  to  the  heat 
of  a  quick,  hot  oven  for  from  twenty  to  thirty  minutes.  In 
making  toast,  what  happens  ?  The  toasting  destroys  all  yeast 
germs  and  other  germs  which  may  be  with  the  bread,  and  thus 
the  toast  is  sterile.  Surely  a  great  advantage.  The  starch  in 
the  bread,  of  course,  must  be  converted  into  sugar  before  it 
can  be  assimilated.  The  toasting  does  this  in  part.  Carry  the 
toasting  still  further,  and  we  convert  the  starch  into  dextrin, 
a  gummy  substance.  Carry  the  toasting  still  further,  and  we 
get  the  dark-brown  and  even  black  toast,  the  sugar  being  cara- 
melized, and  the  flavor  is  improved.  Steam  the  toast,  and  you 
further  dextrinize  the  starch.  Butter  it  lightly,  and  you  make 
it  more  digestible  by  dijffusing  it,  as  it  w^ere,  and  the  saliva  acts 
better  on  it,  in  first  starting  starchy  digestion,  which  is  con- 
tinued after  swallowing  by  the  amylopsin  in  the  pancreatic 
juice  and  diastase  in  the  intestinal  juices  with  some  other 
digestive  substances. 

Another  bread  is  very  digestible :  Take  light  dough,  roll  it 
very  thin,  cut  it  into  strips,  roll  it  into  hollow  cylinders,  and 
bake  ver}^  quick  and  dry.  You  here  have  bread  cylinders, 
very  digestible,  about  the  same  as  toast.  Crackers  are  not, 
as  a  rule,  ver}^  digestible,  because  they  are  baked  as  very  dry 
dough,  not  much  water  being  added,  and  thus  the  starch  gran- 
ules are  not  well  broken  up,  and  the  cracker  is  thus  more  diffi- 
cult to  digest.  To  be  digestible,  all  starches  must  be  well 
cooked,  with  sufficient  water  to  soften  the  granules  and  break 
up  the  cell-structure.  Pretzels  are  superior  to  crackers  as  an 
article  of  diet,  because  the  dough  is  here  first  boiled  well, 
which  breaks  up  the  starch,  and  then  thoroughly  baked. 
There  is  generally  too  much  salt  about  them,  for  the  carry- 

229 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

ing  of  Avhich,  it  is  said,  they  were  invented,  to  make  the 
lounger  drink  two  glasses  of  beer  when  otherwise  one  would 
have  sufficed.     This,  doubtless,  is  a  libel  on  Boniface. 

I  applied  to  Dr.  Neale,  the  director  of  the  Delaware  Col- 
lege Agricultural  Experiment  Station  at  Newark,  Delaware, 
for  his  views  on  the  effect  of  toasting  on  bread.  He  wrote 
to  Professor  Atwater,  the  well-known  expert  on  food  analy- 
sis. Professor  Atwater  referred  the  question  to  Professor 
Woods,  and  I  take  great  pleasure  in  appending  Professor 
Woods's  very  satisfactory  reply. 

"  Maine  Agricultural  Experiment  Station, 
"  Orono,  Maine,  December  13,  189S. 
"  Chas.  D.  WoodSj  Director. 

"  Director  Arthur  T.  Neale,  Agricultural  Experiment  Station, 
Newark,  Delaware : 
"  Dear  Doctor  Neale, — Your  letter  of  December  9  to  Professor  At- 
water has  been  forwarded  to  me  for  reply.  I  wish  I  could  tell  you  a 
great  deal  more  than  I  can  relative  to  the  changes  which  take  place  in 
bread  by  toasting.  While,  as  you  know,  there  has  been  a  very  large 
amount  of  work  done  upon  bread,  comparatively  little  of  it  has  brought 
definite  information.  As  is  well  known  to  you,  the  difference  between 
fresh  bread  and  stale  bread  is  not  due  to  a  loss  in  water,  but  to  a  molec- 
ular change.  In  the  process  of  baking  there  is  probably  a  distillation  of 
water  from  the  surface  which  is  recondensed  in  the  more  central  parts  of 
the  loaf.  In  cooling,  the  reverse  goes  on.  It  is  believed,  rather  than 
known,  that  in  fresh  bread  the  greater  part  of  the  water  is  free,  while  in 
stale  bread  part  of  the  water  is  combined  with  the  starch,  or  perhaps  with 
gluten,  and  that  these  are  again  separated  when  the  loaf  is  reheated.  In 
toasting,  water  is  driven  off  and  a  greater  firmness  is  acquired.  If  the 
slice  is  thick,  and  the  surface  is  merely  scorched  by  the  action  of  the 
heat,  as  is  the  case  in  most  restaurant-  or  hotel-made  toast,  the  interior 
changes  are  very  much  the  same  as  when  stale  bread  is  rebaked.  On  the 
other  hand,  when  bread  is  thoroughly  toasted,  so  that  crispness  extends 
throughout  the  slice,  there  is  quite  a  large  loss  in  water,  much  of  the  starch 
is  changed  to  dextrin,  and  some  of  it  is  even  converted  into  caramel,  or 
substances  closely  related  thereto.  The  peculiarly  pleasant  burnt  taste 
is  probably  due  to  caramel,  the  sweeter  taste  and  the  apparently  greater 
ease  of  digestion  is  probably  due  to  conversion  of  a  considerable  part  of 
the  starch  into  dextrin.  It  is,  however,  probably  true  that  much  of  the 
apparent  increased  ease  of  digestibility  of  the  toast  over  the  bread  from 
which  it  was  prepared  is  due  to  a  change  in  mechanical  condition,  so  that 
in  mastication  it  does  not  pack  in  the  way  that  even  stale  bread  does.  I 
think  that  the  above  includes  all  that  is  known  of  the  chemistry  of  toast- 
ing, as  well  as  some  things  which  are  merely  inferred. 

"  Respectfully, 

230  "  C.  D.  Woods." 


FORTY    YEAKS    IN    Till".    M\'A)\CA\.    I'KOFESSION 

The  latest  treatment  for  fatness  is  the  alternate  drinking 
of  Kissint^en  and  Vichy,  tlie  watci"  of  the  (irande  (jrille  pre- 
ferred. Dr.  William  T.  Cathcll,  in  the  Maryland  Medical 
Journal,  recommends  that  a  full  ^lass  of  Kissinj:(en  he  taken 
one-half  hour  after  each  meal,  and  the  next  day,jn  the  same 
way,  a  glass  of  Vichy;  alternating  in  this  way,  the  artificial 
waters  may  he  used,  or  the  waters  ])re|)ared  with  the  various 
effervescing  salts  on  the  market.  If  the  patient  loses  more 
than  two  pounds  in  weight  per  week,  take  a  small  glass,  or 
omit  the  mid-day  glass.  If  he  loses  less  than  two  pounds  per 
week,  add  the  juice  of  half  a  lemon  to  each  glass  of  Kissingen, 
or  a  teaspoonful  of  the  aromatic  spirit  of  ammonia  to  each 
glass  of  Vichy.  It  is  not  necessary  to  restrict  the  diet,  but 
cut  down  somewhat  alcoholics,  starch,  sugar,  and  fats,  if 
given  to  consuming  large  quantities  of  them.  In  other  words, 
avoid  overeating  and  excesses  at  the  table.  Sleep  on  an  empty 
stomach  as  near  as  possible,  so  some  of  the  surplus  fat  may  be 
burned  up  as  fuel  whilst  we  sleep.  Take  plenty  of  out-door 
exercise,  to  promote  tissue  oxidation.  If  more  convenient, 
the  patient  may  take  one  glass  of  Vichy  before  breakfast,  and 
a  glass  of  Kissingen  just  before  going  to  bed,  and  expect  good 
results.  There  is  no  doubt  that  even  sipping  the  waters  now 
and  again,  to  the  amount  of  from  three  to  four  glasses  per 
day,  alternating  between  Kissingen  and  Vichy  by  days,  would 
prove  equally,  if  not  more,  effectual.  Taking  these  waters 
may  be  kept  up  from  one  to  six  months,  or  longer  if  necessary. 
I  may  add  here  that  this  is  not  a  new  system  of  treating  obe- 
sity, but  is  a  revival  of  the  Dancel  system, — giving  sodium 
bicarbonate  with  tartaric  acid  and  water  in  the  effervescing 
state.  How  do  they  act?  Well,  they  may  act  in  several  ways. 
By  merely  inhibiting  or  controlling  the  disproportionate  ac- 
tivity of  fat-cell  nutrition,  thus  placing  less  fatty  pabulum  and 
more  blood,  brain,  muscle,  nerve,  and  gland  elements  at  the 
disposal  of  the  absorbents,  whilst  the  fat  and  oil,  being  of 
lower  organization,  are  naturally  the  first  to  be  removed  by 
the  corrected  physiological  processes,  or  they  may  act  as  alter- 
atives and  restore  equilibrium  to  the  nutritive  processes  by 

^31 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

destroying  or  neutralizing  some  morbific  fat-forming  agency, 
occult  derangement  of  digestion,  or  perversion  of  assimilation 
that  have  been  causing  diminished  oxidation  of  fat  and,  con- 
sequently, its  accumulation. 

Another  supposition :  Kissingen  and  Vichy,  the  former 
acid  and  the  latter  alkaline,  and  both  containing  salts  of  lime, 
magnesia,  potash,  soda,  and  other  minerals,  united  with  car- 
bonic acid  and  other  gases,  may,  when  alternately  mingled 
with  the  chyme  in  the  stomach  and  intestines  day  after  day, 
— their  special  combination  of  ingredients, — ^bring  about  re- 
duction by  some  chemico-physiological  readjustment  of  the 
alkalinity  and  acidity  of  the  blood  and  the  visceral  fluids,  or 
possibly  of  both  humors  and  solids,  and  that  this  readjust- 
ment makes  the  fat-yielding  pabulum  less  plentiful  and  less 
rich,  less  favorable  for  fat  creation,  and  metabolically  ex- 
plains why  increase  of  fatness  ceases  and  why  reabsorption 
of  the  surplus  contents  of  the  fat-cells  begins,  and  also  why 
this  physiological  reduction  and  reconstruction  results,  and 
thus  reduces  the  fat  of  the  body  to  the  normal  proportion  of 
one  to  fifteen  or  twenty.  Whether  Dr.  Cathell  is  correct  here 
or  not,  he  declares  that  practically  they  work  wonders,  and 
the  individual  losses  are  from  fifteen  to  ninety  pounds.  My 
experience  in  practice  confirms  somewhat  Dr.  Cathell's. 

In  matters  of  diet,  we  spoke  of  studying  the  individual  in 
ordering  a  course  of  diet  for  a  patient.  Climate  is  also  an 
important  matter  to  take  into  consideration.  The  Esquimau 
needs,  from  his  environment,  much  fat  to  keep  up  the  heat  of 
his  body,  but  what  would  the  inhabitant  of  Manila  do  with 
blubber  as  a  main  article  of  diet,  living  constantly  as  he  does 
under  the  hot  rays  of  an  equatorial  sun?  Our  soldiers  in 
Manila  do  not  want  blubber,  but  experience  shows  that 
we  must  still  keep  the  fat  in  their  ration.  According  to 
George  Waldron,  Ireland  eats  more  white  potatoes  than  any 
other  nation,  consuming  a  daily  average  of  four  pounds  per 
person.  Germany  comes  next,  and  Italy  last,  consuming  only 
forty-eight  pounds  per  person  per  year.  The  United  States 
consumes   two    hundred    pounds   per   person   per    year.      In 

232 


FORTY    YEARS    IN    TIIIC    MKDICAL    I'RDFKSSION 

wheat,  France  leads  the  hst,  using  f(>ur  hun<h-e(l  and  sixty- 
seven  pounds  per  person  per  year.  Canada  comes  next.  The 
United  States  cfjnsunies  two  liundred  and  f(jrty  ])ounds  per 
person  per  year.  Japan  uses  only  tvventy-tvvtj  jKnmds  per  per- 
son per  year,  wiiich  is  just  the  amount  of  rye  used  by  each 
person  in  the  United  States.  Norway  uses  the  most  oats  per 
person,  being  one  hundred  and  twelve  pounds  per  person  per 
year.  England,  including  Scotland  and  Ireland,  uses  only 
twelve  pounds  of  oats  per  person  per  year, — very  remarkable, 
so  much  of  it  being  used  in  Scotland,  and  such  an  ideal  food 
for  the  climate.  In  meats,  the  United  States  stands  at  the 
head,  using  one  hundred  and  forty-seven  pounds  per  person 
per  year.  Italy  uses  the  least,  as  her  climate  might  indicate — 
twenty-four  pounds  per  person  per  year.  The  United  States 
also  uses  more  eggs  than  any  other  country  per  person, — one 
hundred  and  twenty-three  per  year.  In  rice,  the  United  States 
takes  only  four  pounds  per  person  per  year.  Great  Britain 
takes  nine  pounds,  and  the  province  of  Bombay,  India,  uses 
five  hundred  and  forty-seven  pounds  per  person  per  year. 
Here  we  see  how  climate  comes  in  in  diet.  In  sugar,  Great 
Britain  uses  the  most. — eighty  pounds  for  each  inhabitant  per 
year.  The  United  States  uses  seventy-three  pounds,  and 
Spain  only  seven  pounds.  In  tea.  Great  Britain  leads, — about 
five  and  one-half  pounds  per  person  per  year.  Russia  uses 
only  nine  ounces  per  person  per  year,  and  yet  are  supposed 
to  be  a  tea-drinking  people.  Here  we  see  the  condition  as 
shown  by  diet, — too  poor  to  drink  much  tea.  In  coffee,  the 
Netherlands  use  the  most,  over  twenty-three  pounds  per  per- 
son per  year,  whilst  we  use  nearly  ten  pounds.  Russia  uses 
only  three  ounces  per  person  per  year.  In  malt  liquors.  Great 
Britain  takes  the  lead,  thirty  gallons  to  each  person  per  year. 
actually  leading  Germany  three  gallons  per  individual.  We. 
in  the  United  States,  use  fifteen  gallons  per  person  per  year. 
In  the  wine-drinking  countries  comparatively  little  is  used, 
although  it  is  increasing  in  France,  she  now  using  six  gallons 
per  person  per  year.  Spain  uses  only  a  little  over  a  pint,  but 
in  wine  consumption  Spain  leads  the  world, — thirty-five  gal- 

233 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Ions  to  each  person  per  year.  France,  twenty-nine  gallons, 
and  Italy,  twenty-four  gallons.  It  is  interesting  to  note  that 
the  United  Kingdom  uses  less  than  two  cjiiarts  per  person  per 
year.  Her  climate  demands  something  stronger.  Surprising 
to  say,  Germany  uses  only  a  little  over  one  gallon  of  wine  per 
person  per  year.  In  the  United  States  the  consumption  of 
wine  is  rapidly  increasing,  but  it  is  yet  only  two  quarts  to 
each  person  per  year,  making  the  respectable  quantity  of 
thirty-eight  million  gallons.  Great  Britain  and  her  colonies 
and  Russia  are  among  the  great  spirit-drinking  countries,  and 
climate  here  is  the  great  factor  in  determining  the  quantity 
consumed. 

It  has  been  said  that  "  a  piece  of  charcoal,  some  atmospheric 
air,  a  little  water,  and  some  salt  contain  all  the  elements  of  a 
typical  diet,  and  in  ample  quantity,"  but  we  cannot  live  on  a 
piece  of  charcoal,  some  atmospheric  air,  a  little  water,  and 
some  salt  served  in  kind  at  least,  but  dress  them  up  in  palata- 
ble dress,  and  we  take  them  with  avidity  and  grow  fat,  show- 
ing it  is  not  altogether  the  elements  the  food  contains  that 
make  it  available,  but  how^  and  in  what  way  these  elements 
are  contained  is  the  important  matter.  Another  thing  it 
shows :  we  must  know  something  more  than  the  absolute 
chemical  composition  of  food-stuffs  before  we  can  foretell 
exactly  the  effect  on  the  indivdual. 

It  is  now  autumn,  and  a  lady,  married,  with  no  children,, 
of  middle  age,  of  normal  weight,  and  very  bright,  has  just 
asked  me  to  recommend  an  average  diet  for  her,  not  that  she 
is  sick,  for  she  is  very  well,  has  no  vices  and  no  fads ;  she 
merely  wants  to  take  good  care  of  her  present  satisfactory 
health.  I  suggested  the  following:  For  breakfast,  she  being 
always  ready  for  it  at  eight  a.m.,  a  baked  apple  or  pear,  not 
very  sweet,  with,  if  she  prefers,  some  milk  that  has  been  Pas- 
teurized. If  preferred,  a  few  grapes  or  a  peach  may  be  eaten,, 
without  sauce,  au  naturcl.  A  plate  of  oatmeal,  wheaten  grits, 
or  corn  grits,  with  Pasteurized  milk  but  no  sugar,  stale  bread 
with  butter,  and  a  cup  of  coffee  and  hot  milk.  If  preferred, 
tv^o  hen's  eggs  boiled  from  three  and  one-half  to  five  minutes 

234 


FORTY    Yl'.ARS    IN    'lillC    MI-:i)ICAL    I'KOI- MSSION 

may  be  su1)slitutc(l  for  tlie  oatmeal  or  ji^rits.  I.iincheon,  one 
P.M. :  some  Hji^^lit  soup,  with  stale  bread  and  butter,  some 
boiled  fresli  fish,  and  some  plain  fruit.  Pr()vided  she  is  not 
to  take  active  exercise  for  an  hour  or  two,  a  chop  or  some 
minced  meat  or  a  bird  may  take  the  place  of  fish.  If  desired, 
a  well-baked  white  potato  may  be  added  to  this  meal.  Din- 
ner, six  P.M. :  a  soup,  not  rich,  such  as  consomme  or  a  clear 
vegetable  soup,  choice  of  roast  or  boiled  beef,  mutton,  or  poul- 
try, or  its  equivalent;  baked  white  potato  or  sweet  potato, 
and  either  rice  or  macaroni,  with  either  cauliflower,  spinach, 
or  cabbage,  boiled,  with  a  plain  sauce.  A  light  salad  may 
follow,  with  a  taste  of  cheese  and  a  taste  of  hard  cracker 
heated.  If  any  wine  is  used,  take  claret  and  water.  For  des- 
sert take  plain  rice-pudding,  plain  custard,  or  a  little  light 
pastry,  some  fruit  if  desired,  with  a  dcnii-tassc  of  coffee.  If 
the  custom  of  her  home,  then  a  sociable  cup  of  mild  black  tea, 
without  cream  or  milk,  one  hour  after  dinner,  may  take  the 
place  of  the  coffee. 

Merely  as  a  matter  for  reference,  I  will  give  the  time  re- 
quired for  the  digestion  of  some  of  the  commoner  articles  of 
diet.  May  I  preface  this  with  one  admonition?  In  cooking 
in  general,  avoid  the  frying-pan,  as  a  rule,  and  rich,  various- 
flavored,  wonderfully  made  sauces.  The  frying-pan  makes 
easy  a  cheap  and  indolent  method  of  preparing  food.  It  has 
been  said  that  words  were  made  with  which  to  disguise  our 
thoughts.  The  French,  particularly,  invented  the  various 
sauces  to  disguise  natural  flavors  and  to  enable  them  to  serve 
any  dish  from  almost  any  material,  thus  serving  two  purposes, 
— the  satisfying  the  palate  of  the  guest  and  establishing  an 
economical  method  in  the  kitchen.  None  of  these  methods 
are  conducive  to  the  good  health  and  prosperity  of  the  indi- 
vidual. Time  required  for  the  digestion,  or  rather,  tJie  eJiymi- 
Hcation  of  various  articles  of  food:  Boiled  beef,  2^  hours; 
roast  beef,  3  hours ;  boiled  mutton,  3  hours ;  roasted  mutton, 
3^4  hours;  turkey  roasted  or  boiled,  2^4  hours;  stewed 
chicken,  2^/4.  hours;  fried  beef,  4  hours;  roasted  chicken  and 
duck.  4  hours ;    boiled  chicken.  4  hours ;    roasted  fresh  pork. 

235 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

5^  hours ;  soused  pig's  feet  boiled,  i  hour  only,  and  tripe  the 
same;'  venison  steak  broiled,  i^  hours;  fried  brains,  i}i 
hours;  fried  beef  liver,  2^  hours;  calf's  liver,  1%  hours; 
roasted  goose,  2^  hours;  roasted  young  pig,  23^  hours; 
roasted  lamb,  2^  hours;  boiled  salmon,  13^  hours;  boiled 
salt  cod,  2^/2  hours;  stewed  oysters,  3^/2  hours;  raw  oysters, 
much  less;  cheese,  3^  hours;  gelatin  is  digested  in  from  2^ 
to  3  hours,  cartilage  in  4^  hours,  and  tendon,  well  cooked,  in 
6  hours;  raw  eggs,  13^  hours;  roasted  eggs,  2^4  hours;  hard- 
boiled  eggs,  3^4  hours ;  fried  eggs,  3^  hours ;  soft-boiled  eggs, 
2  hours;  boiled  lean  ham  is  quite  easy  of  digestion;  boiled 
white  potatoes,  33^  hours;  if  well  baked  or  roasted,  2  to  2}i 
hours;  boiled  cabbage,  4  hours;  boiled  turnips,  3J^  hours; 
boiled  rice,  i  hour;  boiled  beans,  23^  hours,  and  the  same 
for  boiled  parsnips;  carrots,  boiled,  from  3^4  to  3^  hours; 
baked  wheat  bread,  33^  hours;  boiled  beets,  4  hours;  boiled 
or  baked  apple-dumpling,  3  hours ;  raw  apples,  from  i  ^  to  2 
hours, — sweet  and  mellow  digest  the  soonest;  corn-bread, 
334  hours;  hoe-cake,  3  hours;  sponge-cake,  3  hours;  boiled 
barley,  2  hours,  tapioca  the  same,  and  sago  about  the  same. 
Sugars  are  very  rapidly  absorbed  from  the  stomach,  and,  as 
a  rule,  so  are  fats.  Of  course,  digestion  may  be  retarded  by 
different  causes,  as  by  food  that  does  not  agree  with  one,  such 
as  unripe  fruit,  badly  cooked  food,  animal  food  too  tough  to 
be  eaten,  etc.,  together  with  the  stones,  seeds,  and  skin  of 
fruits  and  such. 

I  cannot  quit  this  subject  without  saying  something  of 
7nilk  as  food  for  man,  the  support  of  his  early  infant  days 
and  his  last  resource  if  toothless  old  age  overtakes  him.  As 
a  general  thing,  unless  otherwise  stated  the  milk  of  the  cow 
is  referred  to  in  this  connection.  Another  thing  remember : 
milk  is  really  a  complete  food,  and  its  indiscriminate  use  as  a 
beverage  by  those  who  already  eat  a  full  supply  of  regulation 
diet  is  to  be  condemned  as  superfluous.  When  used  properly, 
by  sick  or  well,  under  the  guidance  of  proper  medical  advice, 
there  is  nothing  to  equal  it,  and  no  tonic  devised  by  man,  as 
tonics  are  understood,  can  in  any  way  approach  milk ;   but  as 

236 


FORT^'    YI'lAKS    IN    TinC    AllCDICAI.    I'Is'f )l'i;S.SIOX 

a  tonic  milk  cannot  be  used  alone.  Matured  man  cannot  live 
and  thrive  on  milk  alone;  something  else  must  accompany  it 
in  the  ration.  Besides,  if  he  lives  alone  on  milk  he  soon  gets 
tired  of  the  monotony,  and  for  good  reason.  It  takes  nine 
pints  of  milk  at  a  specific  gravity  of  1030  or  over  to  give  him 
the  twenty-three  ounces  of  dry  food  neerled  for  his  daily  al- 
lowance, and  whilst  taking  this  much  he  gets  too  much  albu- 
min, fats,  and  water,  for  he  does  not  need  so  much.  This  is 
all  right  for  the  growing  infant.  It  needs  more  of  these,  and 
can  live  on  milk  alone  for  a  considerable  time,  but  it  should 
drink  some  sterilized  water  in  addition,  an  important  matter 
very  often  overlooked,  otherwise  they  become  dyspeptic  and 
wretched  and  cross.  I  say  sterilized  water,  for  it  is  safer, 
and  the  water  of  the  milk  keeps  intact  the  cell  protoplasm 
if  sterilized  or  distilled  water  will  not  accomplish  this, 
or  even  injures  it.  Hemorrhagic  troubles,  uric  acid  trou- 
bles, and  troubles  of  a  pigmentous  kind  are  common  among 
young  children,  and  water  is  useful  in  carrying  off  the  debris 
of  the  system  which  accumulates  rapidly,  the  red  corpuscles 
of  the  blood  being  rapidly  destroyed  at  this  age  and  lithic 
formations  frequent.  I  think  three  pints  of  good  milk  in 
iwenty-four  hours  will  support  life  in  a  natural  man,  but  it 
surely  is  not  a  working  ration.  The  chemical  composition  of 
milk  has  already  been  given, — protein,  3.3;  fat,  4;  carbohy- 
drates, 5  ;  ash,  7;  and  water.  The  lactose,  or  milk-sugar,  is  an 
important  ingredient  in  milk.  It  is  ecj[ual.  usually  to  half  the 
solids  of  the  milk,  leaving  out  the  fats.  It  sours  the  milk  by 
being  converted  into  lactic  acid  during  the  fermentation  of  the 
milk,  caused  by  nitrogenous  materials  in  it.  Great  reforms  are 
still  needed  in  milk  inspection,  from  the  environment  of  the 
cow,  through  the  cow,  and  through  all  of  its  phases,  up  to  the 
time  it  is  used  as  an  article  of  food.  It  is  an  ideal  host  for 
most  of  the  pathogenic  and  other  microbes,  and  when  we  come 
to  think  of  their  universal  presence,  under  all  circumstances 
and  at  all  times,  we  soon  see  how  it  is  impossible  to  guard  too 
closety  and  too  jealously  all  that  pertains  to  this  universal 
nourishment  of  man.     I  believe  that  twenty  per  cent. — surely 

237 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

not  less  than  fifteen  per  cent. — of  the  cows  furnishing  the 
milk  supply  to  the  people  of  the  Middle  States  are  tubercu- 
lous, and  some,  at  least,  of  these  have  tuberculosis  of  the 
udder.  These  last,  at  least,  surely  furnish  milk  contaminated 
by  tubercle  bacilli,  and  wdien  I  say  I  believe  such  milk  unster- 
ilized  can  reproduce  tuberculosis  in  man  in  its  various  forms, 
is  it  not  right  and  proper,  is  it  not  our  bounden  duty,  re- 
gardless of  expense,  regardless  of  any  obstacle  whatever,  to 
do  all  in  our  power  to  eradicate  such  a  menace  to  human 
health,  such  a  bar  to  human  happiness?  Can  man  be  so  base, 
so  mean,  so  low,  as  to  reckon  in  dollars  and  cents  the  price  of 
any  means  to  be  used  to  eradicate  this  evil,  probably  the  evil 
of  all  evils  now  confronting  him  ?  Oh,  the  fond  friends,  from 
the  darling  prattling  infants  to  those  the  brightest  and  love- 
liest of  matured  age,  we,  all  of  us,  without  exception,  are 
mourning,  have  mourned,  and  will  never  cease  to  mourn,  un- 
fortunate victims  of  this  greatest,  most  unrelenting  of  all  the 
scourges  inflicted  upon  the  human  race ! 

Milk  being  such  a  good  host  for  pathogenic  germs,  I  be- 
lieve it  should  in  some  way  be  sterilized  before  it  is  taken  for 
food  into  the  human  stomach,  and  probably,  in  the  end,  Pas- 
teurizing is  the  best  method  of  accomplishing  this.  It  surely 
leaves  the  milk  in  the  most  palatable  condition  of  any  of  the 
methods,  and  there  is  only  one  loop-hole  of  escape  for  error, 
and  that  is,  are  the  spores  thoroughly  destroyed  by  Pasteur- 
izing, as  thoroughly  destroyed  as  are  the  parent  germs? 
Therefore,  if  you  keep  Pasteurized  milk  any  time,  Pasteurize 
it  once  every  twenty- four  hours,  to  destroy  the  spores  as  they 
arise.  To  sterilize  milk,  bring  it  to  boiling,  212°  F.  To  de- 
stroy the  spores  absolutely  and  surely,  bring  it  to  the  boiling 
point  a  second  time.  To  keep  it,  put  it  in  bottles,  being  sure 
first  to  sterilize  the  bottles  by  boiling  them.  Stop  them  with 
cotton  which  has  been  sterilized  by  baking  in  an  oven  from 
twenty  to  thirty  minutes.  The  cotton  is  better  than  a  solid 
cork,  for  it  allows  escape  from  within  and  checks  entrance 
of  microbes  from  without.  If  you  boil  the  milk  twenty  min- 
utes, it  will  really  digest  better  than  if  you  only  sterilize  it. 

238 


FOR'I'Y    YIOAKS    IN    'nil'.    M  l':i)ICAI,    J'R(;I'l':SSIO\ 

To  young'  infants  raw  milk  is  an  anti-scorbutic,  and  Professor 
IJartholow  and  others  think  sterilizinj^  it  may  take  away  this 
])ro|)crty  in  a  measure.  According-  lo  Leeds,  as  stated  by 
'Thompson,  sterilizing-  niilk  destroys  the  amylolitic  ferment, 
checks  the  coagulating-  of  the  casein  by  rennin,  retards  the 
digestion  of  the  casein,  and  checks  somewhat  the  absorption 
of  the  fat,  and,  if  the  boiling  is  prolonged,  the  lactose  is  de- 
stroyed more  or  less.  It  takes  more  sterilized  milk  to  nourish 
an  infant  than  it  does  of  milk  as  from  the  cow. 

To  Pasteurise  milk,  raise  it  to  a  temperature  of  170'^  F., 
and  keep  it  there  twenty  minutes.  It  digests  easier  than  ster- 
ilized milk,  but  does  not  keep  so  well  unless  repasteurized 
daily.  It  is  more  palatable.  Before  any  bottles  in  any  way 
used  about  milk  are  used  the  second  time,  they  should  be  thor- 
oughly sterilized  by  boiling  twenty  minutes.  Bring  the  boiling 
along  slowly,  and  the  bottles,  as  a  rule,  do  not  break.  After 
one  or  two  boilings,  they  appear  to  become  tough.  Always 
rinse  them  with  boiling  water  just  before  use,  putting  some 
borax  or  boracic  acid  in  the  water,  and  use  a  bottle-washer 
that  has  been  just  sterilized.  For  a  substitute  for  mother's 
milk  I  can  recommend  the  following :  Milk,  eight  tablespoon- 
fuls ;  cream,  two  tablespoonfuls ;  water  that  has  been  boiled, 
eight  tablespoonfuls;  pancreatin,  three  grains;  baking-soda, 
ten  grains;  mix  the  milk  and  cream  together,  then  add  the 
pancreatin  and  baking-soda  to  the  water,  and  mix  with  the 
cream  and  milk;  then  Pasteurize  the  whole  mixture.  Very 
rich  Jersey  or  Alderney  milk  will  do  without  the  addition  of 
cream,  using  that  much  more  of  milk.  If  baby  does  not 
thrive  on  this,  subtract  half  the  amount  of  milk,  and  in  its 
place  put  the  same  amount  of  very  strong  barley-water,  rice- 
water,  or  oatmeal-water.  Be  particular  and  never  forget  to 
add  to  this  amount  of  nourishment  as  here  given  (a  little  over 
half  a  pint)  an  even  teaspoonful  of  refined  cane-sugar  and  a 
good  pinch  of  table  salt.  I  prefer  cane-sugar  to  sugar  of  milk 
to  add  to  baby  food. 

There  is  a  healthy  evolution  going  on  in  the  economics  of 
milk,  from  its  production  to  its  consumption  by  the  consumer, 

-o9 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

and  people  are  beginning  to  see  what  a  great  benefit  such  evo- 
lution Avill  afford.  In  the  larger  centres  of  population  per  cent, 
milk  may  be  obtained,  the  physician  giving  his  prescription 
for  the  per  cent,  of  fat,  sugar,  casein,  etc.,  needed  for  an  indi- 
vidual case,  and  a  scientific  vender  filling  this  prescription 
by  compounding  the  milk  needed  artificially,  much  as  the 
recipe  for  artificial  mother's  milk  is  here  given.  The  world 
moves.  Medicine  is  a  progressive  science,  and  medicine  moves 
as  the  world  moves,  although  it  did  appear  to  be  a  good  while 
starting. 

Condensed  milk  is  a  useful  product,  and  as  it  comes  from 
the  original  package  should  be  sterile,  for  in  closing  it  the 
bacteria  are  destroyed  by  heat  and  all  outside  air  is  shut  off. 
Thus,  with  care  in  detail,  we  can  get  an  article  which  some- 
times serves  a  good  purpose  for  the  sick.  For  condensed 
milk  the  condensation  is  usually  to  about  one-fourth  of  the 
original  bulk.  If  condensation  is  carried  still  further,  more 
sugar  is  added.  On  an  average,  condensed  milk  has  added 
to  it  about  forty  per  cent,  of  cane-sugar.  This  prevents  fer- 
mentation. Dilute  condensed  milk  eight  to  ten  times  with 
sterilized  water  for  a  baby  at  birth,  and  add  some  fat  in  the 
shape  of  cream  or  olive  oil.  A  formula,  such  as  this,  will  be 
found  about  correct :  Condensed  milk,  one  teaspoonful ;  cream, 
four  teaspoonfuls,  or  olive  oil,  two  teaspoonfuls ;  hot  water, 
five  tablespoonfuls.  If  oil  is  used,  make  up  the  deficiency  by 
two  teaspoonfuls  more  water.  Pasteurize  for  use.  On  ac- 
count of  the  excess  of  sugar,  condensed  milk  does  not  keep 
long,  and  is  more  apt  than  normal  milk  to  cause  fermentative 
troubles  in  those  using  it.  Add  an  excess  of  fat,  and  it  fre- 
quently proves  a  serviceable  food  for  consumptives. 

Devonshire  cream  is  cream  skimmed  from  heated  milk,  so 
the  albumin  is  coagulated  and  comes  off  with  the  cream,  and 
may  be  substituted  for  cod-liver  oil,  when  such  disagrees. 

Evaporated  milk  is  extra  strong  milk,  the  water  having 
been  driven  off,  and  as  it  is  for  immediate  use,  it  is  au  naturel, 
no  sugar  or  anti-ferment  having  been  added ;  at  least,  this 
should  be  so. 

240 


FORTY    YEARS    IN    Till':    MEDICAI.    PKOFRSSION 

Bullcnuilk  is  milk  witli  the  fat  removed  for  butter.  There 
is  albumin  and  casein  left  in  it,  and  water  and  the  milk  salts, 
with  lactic  acid.  A  man  cannot  live  lonf^  on  buttermilk,  nor 
skim-milk,  that  is,  absolutely. 

Cottage  cheese  or  schmierkase,  or  smearcase,  is  a  very  in- 
viting- help  to  diet,  especially  in  hot  weather,  but  it  is  quite 
hig-h  in  protein,  contains  less  than  half  the  fat  of  pure  milk, 
with  much  lactic  acid  formed  from  the  sugar  as  fermentation 
goes  on. 

Whey  is  another  product,  and  with  wine  is  often  useful, 
especially  for  the  sick.  It  contains  water,  milk  salt,  some 
albumin,  and  lactose  or  milk-sugar;  it  does  not  keep  long, 
and  should  be  sterilized  before  use,  which  may  coagulate  some 
of  the  albumin. 

Let  me  add  here  that  the  distribution  of  the  milk-supply 
should  be  taken  in  hand  by  the  police  power  in  all  communi- 
ties, and  so  should  its  source,  the  cow,  in  all  of  its  environ- 
ments. A  vicious  distribution  of  a  milk-supply  to  any  neigh- 
borhood may  do  more  harm  than  a  pestilence ;  indeed,  it  may 
start  a  pestilence.  There  should  be  a  code  of  laws  to  govern 
this  distribution  in  every  town,  be  it  large  or  small,  and  this 
must  come  sooner  or  later,  as  laws  must  come  to  eradicate 
tuberculosis  from  the  lower  animal  as  the  evolution  of  society 
goes  on  to  perfect  government.  Infected  milk  may  cause  ty- 
phoid fever,  diphtheria,  scarlet  fever,  tyrotoxicon  poisoning, 
Asiatic  cholera,  in  fact,  all  zymotic  diseases,  all  fermentative 
diseases. 

A  milk  called  the  "  Walker-Gordon"'  milk,  from  the  farm 
on  the  golf  links  of  the  Philadelphia  Cricket  Club,  W'issa- 
hickon  Heights,  contains,  on  an  average,  according  to  Dr. 
Samuel  S.  Kneass,  only  354%  bacteria  per  cubic  centimetre. 
This  shows  wonderful  care  in  attention  to  detail,  as  well  as 
careful  selection  of  dairy  stock  and  attention  to  the  environ- 
ment. Where  police  supervision  is  fully  carried  out  over  the 
milk-supply  to  a  community,  no  milk  is  rejected  where  the 
number  of  bacteria  per  cubic  centimetre  does  not  go  o\er  ten 
thousand.  The  smallest  number  does  not  appear  to  be  many, 
16  241 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

but  when  we  come  to  think  of  it,  that  two  germs  by  simple 
fusion'  can  produce  two  of  its  kind  in  one  hour,  and  in  the 
next  hour  four,  and  in  three  days  a  mass  not  countable, — say, 
4,772,000,000,000,000, — we  begin  to  comprehend  what  the 
lower  order  of  life  really  is,  and  the  great  step  between  it 
and  the  evolution  of  man.  To  check  this  formation  of  germs 
many  antiseptics  or  antizymotics  are  used  by  dealers,  and  it 
makes  us  pause  and  reflect  whether  or  not  it  is  not  better  to 
use  them  surrounded  by  proper  guards  than  run  the  risk  of 
this  auto-infection  of  the  milk-supply.  To  the  reckless  and 
careless  and  vicious  antisepsis  may  be  a  protection,  but  the 
enlightened  citizen  will  use  sterilization  in  its  various  forms. 
Benzoic  acid  and  salicylic  acid  uncombined  with  bases  are 
much  used  as  antiseptics  for  milk,  but  borax  and  boric  acid 
are  cheaper  and  more  tasteless.  These  destroy  the  vegetative 
activity  of  the  various  fungi  and  bacteria,  and  thus  check  fer- 
mentation and  decay.  The  dealer  may  extract  five  per  cent, 
of  the  cream  and  add  ten  per  cent,  of  water,  and  escape  detec- 
tion, unless  by  experts. 

In  the  milk-supply  of  London  the  average  number  of  bac- 
teria per  cubic  centimetre  is  500,000,  a  bad  showing  surely. 
Such  figures  startle  us,  and  point  with  no  uncertain  hand  the 
direction  to  take  to  institute  reforms  that  shall  more  than  in 
any  other  direction  reduce  the  amount  of  zymotic  disease,  and 
thereby  check,  in  a  large  degree,  the  mortality  among  the 
human  race  from  this  its  greatest  factor.  We  know  that 
normal  milk  in  the  udder  of  the  cow  is  absolutely  sterile,  and 
consequently  we  know  just  where  the  trouble  begins.  The 
abnormal  cow  may,  of  course,  produce  abnormal  milk  from 
the  udder, — as  the  tuberculous  cow.  The  most  important 
germs  found  in  milk  are  the  bacillus  coli  communis,  com- 
posing ninety  per  cent,  of  all  in  many  cases,  and  this  is  indica- 
tive of  fecal  contamination,  and  shows  dirty  stables  and  bad 
environment  of  the  cow.  Liquefying  organisms  are  also 
found,  and  show  one  of  two  things, — dirty  cans  and  uten- 
sils or  a  needless  exposure  to  a  bad  atmosphere  in  the  stable 
or  dairy-house.     I  believe  one  source  of  evil  is  housing  the 

242 


FORTY    YKARS    IN    Till'.    MKDICAL    PROFESSION 

COWS  too  elaljorately  and  too  closely.  The  finer  Herd-book 
herds,  on  which  vast  sums  of  money  have  been  spent  in  selec- 
tion and  on  their  environment,  are  the  sickly  herds  in  the  end, 
are  the  herds  in  which  we  most  hkely  find  tul)erculosis  and 
such  troubles,  and  I  am  sure  much  or  all  of  this  vulnerability 
to  zymotic  troubles  comes  from  unnatural  envir(jnment.  In 
palace  stiibles,  making  allowance  for  all  difiference  in  climate 
and  the  environment  of  the  plains,  we  see  the  difference  and 
the  cause. 

When  we  come  to  analyze  the  statistics  of  tuberculosis  in 
the  East  and  in  the  West,  the  showing  is  altogether  in  favor 
of  the  Western  cow,  and  the  same  thing  holds  good  of  the 
Indian, — house  him  abruptl3^  and  you  kill  him.  Never  milk 
a  cow  in  its  stable.  Milk  in  the  open  air,  or  in  an  open  shed, 
and  let  no  person  with  any  zymotic  disease  go  near  her. 

Another  germ  is  found  in  milk,  often  abundantly, — the  ba- 
cillus fluorescens.  This  is  that  which  oftenest  lurks  in  impure 
drinking  water,  and  when  found  in  milk  it  has  probably  been 
reduced  by  water,  and  by  infected  water,  too.  The  Experi- 
ment Station  Record  gives  as  the  solid  impurities  in  milk  the 
following  parts  per  million :  In  whole  milk,  2.6  parts ;  ordi- 
nary skim-milk,  2.1  parts;  separator  skim,  .3  part;  cream, 
1.5  parts.  The  impurities  were  largely  particles  of  litter  and 
fodder,  pieces  of  straining  cloth,  etc.  In  many  samples  were 
found  woollen  and  colored  cotton  fibres  from  clothes  of  at- 
tendants. Separator  skim-milk  is  the  cleanest.  Altogether 
this  is  rather  a  cleanly  showing.  In  London  more  pathogenic 
germs  were  found  than  in  the  United  States,  including  the 
oidium  albicans,  the  exciting  cause  of  thrush ;  this  is  well  for 
physicians  to  know,  for  it  is  very  common  in  bottle-fed  babies 
everywhere.  Sulphuric  ether  (as  I  pointed  out  thirty  years 
ago),  locally  applied,  is  a  sovereign  remedy. 

Food  adulterations,  including  milk,  are  encouraged  by  in- 
tense competition,  with  low  prices  and  small  profits,  and  it 
often  becomes  a  question  with  a  dealer  whether  he  shall  give 
up  his  integrity  or  give  up  his  business.  This  is  a  phase  in 
the  evolution  of  bartering,  and  will  in  the  end  gi\'e  way  to 

243 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

better  methods  as  the  development  of  the  better  laws  of  trade 
unfolds. 

Great  advances  have  been  made  in  the  general  treatment 
and  nourishment  of  infants  in  the  last  forty  years.  When  I 
was  a  resident  at  the  Philadelphia  Hospital,  Blockley,  I  had 
the  opportunity  of  seeing  something  of  the  practical  work- 
ings of  the  day  in  a  foundling  hospital,  but  before  I  had  time 
to  more  than  get  a  knowledge  of  the  horrors  of  the  system, 
much  less  attempt  to  apply  remedies,  my  term  had  expired. 
At  that  day  most  of  the  foundlings  of  Philadelphia  came  to 
this  hospital,  and  there  were  quite  a  number  of  these  poor 
little  waifs.  In  winter  or  in  summer  they  nearly  all  died, 
starved  to  death,  as  it  were,  from  too  much  and  ill-advised 
feeding,  paradoxical  as  that  may  appear.  Indeed,  if  one  lived 
beyond  infancy  it  was  a  curiosity.  One  or  two  in  several 
years  did  so  survive,  and  one  named  after  President  Lincoln 
was  always  looked  upon  with  curiosity  as  a  survivor  of  the 
holocaust  of  infants  at  Blockley.  I  am  sorry  to  say  Lincoln 
did  badly  as  he  grew  up  towards  matured  manhood,  and  the 
last  I  heard  of  him  he  was  a  had  man  among  bad  men  of  Ches- 
apeake oyster-men.  Can  you  "  make  a  silk  purse  of  a  sow's 
ear"  ?  But,  "  revenons  a  nos  moutons."  There  was  no  sys- 
tem in  caring  for  these  bereft  babies.  A  good,  well-meaning 
woman  was  at  the  head  of  it,  and  the  doctors  looked  in  if  any- 
body was  ill,  or  if  they  took  sufficient  interest  to  go  oftener. 
Pauper  inmates  from  among  the  women  were  the  nurses.  Im- 
agine such  a  thing  as  asepsis,  the  use  of  antisepsis,  or  any 
attention  to  detail  with  such  a  gang!  You  could  not  trust 
them  with  forty  drops  of  spirits,  nor  with  one  particle  of  a 
narcotic.  The  baby-food  was  milk,  generally  diluted  with 
water,  cold  or  hot,  as  best  suited  the  convenience  of  the  at- 
tendant. There  was  no  special  care  of  the  milk,  no  special 
care  of  the  bottles,  and  the  same  might  serve  for  half  a  dozen 
children,  and,  as  a  rule,  were  fitted  with,  as  I  remember,  the 
long  hose  nipples,  an  abomination,  an  invention  of  the  devil. 
The  babies  did  not  remain  long,  and  the  end  was  a  death  cer- 
tificate of  "  Inanition"  and  a  grave  in  "  Potter's  Field." 

244 


FORTY    YKARS    IN    TITF.    MICDICAL    PROFESSION 

T  remember  about  tbis  time  JJebij^  put  fortb  tlie  formula 
for  bis  food  for  infants.  I  Iiad  it  made,  and  tried  it  on  these 
Httle  ones.  Of  course,  1  bad  no  success.  The  children  were 
too  younji-,  as  a  rule,  and  1  commenced  too  far  away  from 
bed-rock, — sterilization,  asc])sis,  and  antisepsis,  not  only  of 
the  food,  but  of  the  child,  the  whole  environment  from  A  to 
Izzard.  To  properly  care  for  a  bottle-fed  baby,  to  give  atten- 
tion in  a  proper  manner  to  every  detail  (and  in  this  attention 
to  detail  lies  the  whole  secret),  is  full  and  exhaustive  work 
for  any  strong,  healthy,  and  vigorous  woman.  Think  of  this, 
when  we  oftener  see,  yes,  much  oftener,  one  poor,  frail  crea- 
ture caring  for,  in  some  fashion,  with  absolutely  unsanitary 
environment,  not  only  one  bottle-fed  baby,  but  several  chil- 
dren besides ;  and  yet  this  is  not  half  she  does :  she  washes 
and  irons  for  the  family,  does  the  cooking  and  scrubbing, 
makes  the  clothes,  and  does  the  mending  of  the  children  at 
least,  and  entertains  company  in  the  evening  in  her  best  gown. 
Poor  little  bottle-fed  babies !  your  lot  is  a  hard  one ;  no  won- 
der you  continue  to  die  beyond  the  normal  rate  that  should 
prevail  among  you.  Never  mind,  the  good  time  is  coming, 
and  zymotic  disease  shall  less  and  less  prevail  among  men. 
Science  is  leading  mankind  as  a  beacon  to  a  safer  and  better 
harbor. 

The  physician,  in  looking  after  an  infant  under  four  months 
old,  should  first  consider  the  mother,  as  to  the  quality  of  her 
milk,  her  family  history,  her  present  condition  of  health,  etc. 
An  examination  of  her  milk  chemically  is  of  prime  necessity, 
especially  if  the  baby  does  not  thrive.  She  should  nurse  the 
bab}^  altogether  as  near  as  possible  until  it  has  reached  the 
age  of  one  year  at  least.  Whatever  baby  takes,  starchy  and 
other  foods,  should  be  withheld  until  from  four  to  six  months 
have  passed  since  its  birth,  and  no  flesh  should  be  given  until 
the  teeth  have  come  to  chew  and  disintegrate  it.  Broths  may 
be  used  before  meats,  and  sometimes  water  extracts  of  carbo- 
hydrates may  be  necessary  before  four  months  of  age.  As  in 
older  people,  when  looking-  up  the  baby  study  the  individual. 
Nothing  is  truer  than  that  every  case  of  infant-feeding  is 

245 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

a  Study,  whether  it  is  hving  on  the  mother  or  artificially. 
Everything  conies  in  in  this  examination, — family  history, 
its  general  health,  its  form,  the  treatment  it  is  apt  to  receive 
in  feeding,  bathing,  and  general  care,  and  its  clothing.  This 
first  six  months  of  life  is  all-important  to  the  baby,  and  has 
much  to  do,  very  much,  indeed,  as  to  whether  it  may  reach 
vigorous  maturity,  and  become  a  useful  citizen  of  the  com- 
monwealth. If  the  baby  cries,  it  is  either  hungry,  cold,  too 
hot,  or  in  pain ;  a  little  food,  a  blanket,  the  removal  of  super- 
fluous covering,  or  attention  to  the  diet  will  usually  work 
wonders  in  the  crying  baby.  Remember,  in  the  improperly 
fed  infant  nutritional  diseases,  scorbutus,  marasmus,  rickets, 
and  others,  are  apt  to  show  themselves  at  an  early  age,  and 
if  the  infant  should  grow  up  to  adult  age,  only  misery  and 
wretchedness  are  in  store  for  it  and  its  kin.  Remember  the 
size  of  the  baby's  stomach,  and  if  possible  regulate  the  diet  so 
it  will  not  be  necessary  to  vomit  the  surplus,  and  thus  add  to 
the  dangers  of  germ  contamination.  A  child  may  starve,  like 
a  man,  even  when  stuffed,  should  it  not  get  the  properly  bal- 
anced ration.  This  is  as  essential  to  watch,  even  in  children 
well  grown,  as  it  is  in  man.  See  that  they  get  a  properly  bal- 
anced diet,  and  here  is  one  of  the  great  needs  of  the  supervi- 
sion of  a  family  by  a  competent  physician,  now  so  little 
thought  of.  After  a  while  the  doctor  will  be  called  to  stop 
the  child  before  he  gets  sick  from  a  mess  of  sweets,  to  see  he 
gets  no  such  trash.  Now,  often,  the  well-grown  child  eats 
the  mess  of  sweets,  and  the  doctor  is  called  to  cure  him  of  the 
effects  of  his  indiscretion,  much  like  "  locking  the  stable  door 
after  the  horse  has  been  stolen." 

Most  of  the  practice  of  medicine  has  now  to  do  with  women 
and  children,  and  no  one  will  feel  the  good  effect  of  the  con- 
stant care  of  the  coming  actors  in  preventive  medicine  so 
much  as  these  same  women  and  children,  and  ages  hence  the 
race  will  show  the  good  effect  in  a  strongly  developed  and 
perfected  manhood.  If  the  baby  has  to  be  weaned,  and 
weaned  prematurely,  then  comes  the  great  trial.  What  shall 
the  food  be?    Well,  this  will  depend  much  on  the  age  and  the 

246 


FORTY    YEARS    IN    Till':    Ml'.DlCAT.    PROFESSION 

siirroiin(Hnj:^s.  If  under  six  months,  it  must,  as  a  rule,  be 
liquid,  and  the  nearer  to  mf)tlier's  milk  the  better,  and  if  this 
be  departed  from  a  little  animal  broth  is  the  best  help  to  milk. 
Fresh  milk  must  be  a  good  part  of  the  diet.  We  know  not 
exactly  why,  but  if  we  omit  it,  scorbutic  troubles  quickly  show 
themselves,  and  the  physician  must  be  cpiick  to  recognize 
them.  Remember,  condensed  milk  will  not  take  the  place 
of  fresh  cow's  milk  for  artificial  feeding  of  infants.  Watch 
it.  The  baby  will  thrive  for  a  time,  but  for  a  time  only.  It 
lacks  freshness,  and  this  lack  of  freshness  predisposes  to  non- 
thriving  in  the  baby.  That  is  as  much  as  we  know.  Watch 
the  gain  or  loss  of  weight  in  the  baby,  and  you  learn  much  as 
to  its  proper  advancement. 

As  to  infant  foods  of  various  kinds,  some  are  good,  after 
the  baby  is  old  enough  to  take  them ;  some  are  vile  and  bad. 
From  idiosyncrasies  one  baby  may  thrive  on  one  and  starve 
on  another,  and  so  it  ever  will  be  with  man.  An  artificial 
food  for  infants,  and  all  invalids  for  that  matter,  should  have 
the  following  properties  at  least :  It  should  have  some  fresh 
cow's  milk  with  it  in  feeding,  most  of  the  time  at  least,  to 
give  it  freshness,  that  which  keeps  away  scurvy.  In  the  pre- 
paring of  it  at  the  laboratory  perfect  sterilization  of  every- 
thing should  be  practised.  It  should  have  some  chemical 
approximation  to  mother's  milk,  and  should  also  physiologi- 
cally approach  it.  If  it  does  not  agree  with  the  child  at  once, 
do  not  persist  in  it;  change  to  another;  sometimes  the  coad- 
ministration of  digestive  ferments  and  digestive  enzymes  may 
help  these  foods.  It  will  try  the  patience  of  any  man  as  he 
has  to  deal  with  the  diet  of  infants  deprived  of  their  proper 
food.  After  all,  as  science  advances,  various  modifications  of 
milk  must  be  our  chief  reliance.  Science  aids  us  much  at  pres- 
ent, but  mere  empiricism  is  still  a  part  of  our  dependence.  The 
coming  artificial  food  will  be  one  not  for  all  babies,  but  will 
probably  be  graded  to  age  and  must  be  one  approaching  more 
or  less  the  composition  and  effect  of  mother's  milk.  Com- 
mercialism must  not  have  a  part  in  the  coming  baby  food. 
Honest  men.  satisfied  with  a  moderate  profit,  must  make  it. 

247 


FORTY    YF.ARS    IN    THE    MEDICAL    PROFESSION 

When  baby  is  sick,  let  the  physician  investigate  the  source 
of  the  food-supply,  whether  from  the  mother  or  from  arti- 
ficial sources,  and  he  will  probably  find  out  the  cause,  even 
if  he  has  to  take  in  the  whole  routine  of  the  milk-supply  in 
the  community,  and  the  entire  culinary  details  of  the  house- 
hold. 

We  have  spoken  of  the  diet  for  childhood,  and  of  diet  for 
the  active,  strong,  and  vigorous  youth,  and  for  vigorous  mid- 
dle age.  When  one  reaches  fifty  years  of  age,  having  escaped 
the  pitfall  of  dissipation,  and  enters  upon  this  stage  of  life 
sound  in  mind  and  body,  it  behooves  to  pay  great  attention 
to  ^^•hat  one  eats  and  what  one  drinks.  These  remarks  apply 
more  particularly  to  the  idle  and  well-to-do,  and  to  those  who 
do  brain-work  more  than  manual  labor.  For  those  working 
with  their  hands  the  all-important  part  is  a  properly  balanced 
ration  and  proper  preparation.  Persons  who  reach  fifty,  of 
the  well-to-do  class  particularly,  eat  too  much  and  eat  too 
often,  and  take  insufficient  exercise,  and  thus  grow  fat  and 
corpulent,  not  working  off  the  excess  as  they  did  in  the  earlier 
and  more  active  periods  of  life.  Especially  is  this  the  case 
with  men  who  retire  to  enjoy  a  well-earned  competency,  and 
which  so  often  ends  in  disaster  to  their  health,  giving  us  an 
object-lesson  that  it  is  better  to  wear  out  than  to  rust  out.  No 
one  should  go  from  an  active,  busy  life  and  drop  into  a  lazy, 
useless  one.  It  is  never  too  late  to  take  up  some  occupation, 
no  difference  what,  so  it  gives  some  rational  employment  to 
body  and  mind.  Some  study  and  practical  work  in  nature  is 
the  best, — agriculture,  horticulture,  and  such,  and  what  comes 
out  of  them  and  with  them,  as  botany,  etc.  At  fifty,  remem- 
ber old  age  is  approaching,  and  the  average  man  is  sick  ten 
days  in  the  year,  only  being  sick  four  days  at  twenty.  At 
fifty  the  blood  loses  some  of  its  richness  and  loses  in  quantity. 
The  blood-vessels  enlarge  and  are  not  so  elastic,  and  the 
dangers  of  atheroma  are  upon  us,  causing  liability  to  apo- 
plexy, etc.,  the  natural  way  for  old  people  to  die.  The  heart 
weakens  somewhat,  probably  a  provision  of  nature  to  reduce 
the  blood-pressure  and  thus  relieve  the  pressure  on  the  blood- 

248 


FORTY    YI'.ARS    IN    'II 1 1-.    MI'IMCAL    PROFRSSION 

vessels,  now  beccjming  weak  like  the  tubes  in  an  (jld  steam- 
boiler.  At  sixty  a  general  shrinkage  begins,  or  is  well  under 
way,  and  continues  on  progressively  into  extreme  old  age, 
accompanied  by  the  loss  of  teeth,  a  weakened  digestion, 
causing  distention  of  the  stomach  and  bowels,  thus  pressing 
up  against  the  diaphragm  and  interfering  with  comfortable 
and  satisfactory  respiration.  Thus  metabolism  is  interfered 
with  and  tissue  changes  go  on.  Katabolism,  retrograde  meta- 
morphosis, is  active,  anabolism — the  building  up  of  tissues, 
the  building  up  of  living  tissue,  the  forming  of  protoplasm, 
without  which  there  is  no  life,  from  nutrient  material,  in  other 
words,  assimilation — becomes  less  active,  and  the  body  hence 
thrives  less  and  less  as  age  increases. 

Men  and  women  at  fifty  should  begin  to  cut  down  their 
nitrogen  particularly  in  their  diet.  7\t  this  age  one  should 
dine  not  more  than  twice  a  week :  twdce  a  week  we  may  live 
to  eat,  five  times  a  week  w^e  should  eat  to  live.  If  w^e  take 
wine,  one  wine  should  suffice.  If  champagne,  it  should  be 
very  dry.  No  one  should  take  sw^eet  champagne  after  fifty. 
I  am  speaking  of  the  w^ell-to-do  and  in  good  health,  and  not 
of  invalids.  The  clarets  and  light  Burgundies  would  be  bet- 
ter. Port,  Madeira,  and  sherry  are  most  dangerous  of  all,  in 
the  order  here  given.  Remember,  after  fifty,  avoid  alcohol 
as  much  as  possible,  and  shade  off  your  tobacco  if  you  use  it 
to  excess.  As  w^e  come  to  sixty  years,  it  is  still  more  of  im- 
portance to  be  careful  in  diet  and  to  take  the  proper  ration. 
Arteriosclerosis  and  its  consequences  are  what  Ave  wish  to 
avoid.  Milk  or  its  equivalent  becomes  more  and  more  an  im- 
portant and  proper  article  of  diet.  If  the  appetite  is  very 
strong,  curb  it.  Do  not  eat  richly  and  drink  generously  and 
then  complain  you  cannot  breathe  properly,  are  uncomforta- 
ble. The  reason  is  you  cannot  digest  properly  what  you  have 
taken ;  your  diaphragm  is  pressed  against  your  natural  breath- 
ing space,  and  you  are  in  a  condition  of  semi-sul¥ocation.  and 
are  laying  rapidly  the  foundation  for  a  miserable  old  age  or 
early  death.  The  gouty  should  take  particular  care  not  to 
overeat.      Semi-starvation  for  these  people  at  times  is  pro- 

249 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

longation  of  comfort  in  living.  After  that  is  gone  what  is 
there  in  life? 

To  those  growing  old  lavage  of  the  bowels  is  of  great  im- 
portance and  a  great  comfort.  Water  in  proper  amount  for 
drinking  is  of  great  importance,  not  too  much  nor  too  little. 
The  skin  does  not  throw  off  as  much,  but  more  is  required  to 
carry  off  nitrogenous  waste.  After  fifty  the  mid-day  luncheon 
should  be  dispensed  with,  or  reduced  to  a  mere  bite,  and  twice 
a  day  is  enough  for  a  hearty  meal.  As  I  said  before,  twice 
a  weak  is  often  enough  to  dine;  let  the  other  dinners  be 
merely  frugal  repasts.  The  elaborate  mid-day  luncheon  as 
usually  set  for  families  or  partaken  of  at  the  restaurant  is  an 
abomination  for  those  over  fifty.  I  am  speaking  now  of  those 
who  breakfast  in  the  morning  and  dine  in  the  evening.  For 
those  who  dine  in  the  middle  of  the  day  the  tea  should  be  only 
a  formal  one. 

The  late  Ward  McAllister,  a  good  authority  on  dining, 
wanted  a  walk  of  ten  miles  and  no  luncheon  as  a  preliminary 
to  a  good  dinner,  and  yet  I  do  not  think  he  took  much  thought 
of  the  chemical  composition  of  his  dinners,  but  catered  to  his 
tastes  chiefly.  I  never  met  Ward  McAllister,  but  in  my  early 
days  I  knew  most  of  the  other  members  of  the  family  welL 
They  were  strong,  staunch  people.  The  father,  the  judge, 
was  a  polished  and  accomplished  gentleman,  and  the  mother  a 
woman  of  lovely  character  and  great  accomplishments.  The 
sons  adorned  the  professions  of  law,  of  arms,  and  the  church, 
and  were  polished  men,  all.  Cutler  was  a  Yale  man,  was 
good  company,  quite  a  wit,  could  sing  a  good  song,  tell  a  good 
story,  and  make  a  good  salad.  Peace  to  his  ashes.  They  are 
all  dead,  barring  the  possible  exception  of  the  sister,  Mrs. 
Francis,  of  New  York  City.  Read  Ward  McAllister's  book, 
and,  having  read  it  and  come  to  moralizing,  you  may  gain 
great  good.  You  may  see  the  dangers  to  the  younger,  at 
least,  among  the  smart  set,  of  being  carried  away  by  dissipa- 
tion in  eating  and  drinking.  Should  they  escape  the  shoals 
here,  you  may  see  the  dangers  they  run  after  fifty  of  gout,  of 
the  horrors  of  dyspepsia,  and  of  the  possibility  of  death  from 

250 


FORTY    YEARS    IN    Till-:    MICDICAL    PROFESSION 

old  age  at  sixty  or  under.  Should  they  escape  all  these  trou- 
bles, or  any  of  them,  at  the  age  given,  you  may  no  longer 
wonder  that  some  men  and  sf)me  women  are  born  with  great 
capacity  for  eating  and  drinking.  But  after  all,  it  is  only 
carrying  out  and  giving  an  object-lesson  of  Darwin's  famous 
law,  that  it  is  (jnly  the  "  fit  who  survive,"  and  no  k^nger  will 
we  wonder  at  the  stories  told  of  the  famous  days  of  ancient 
Rome,  of  her  feasts,  of  her  fair  women  and  more  famous  men, 
and,  whilst  not  forgetting  the  Roman  senators,  I  am  sure  we 
will  modestly  vote,  in  all  that  pertains  to  an  accomplished  and 
polished  host,  Mr.  Ward  McAllister  the  "  noblest  Roman  of 
them  all." 

From  a  combination  of  causes,  but,  after  all,  on  account  of 
the  general  increase  of  intelligence  among  the  people  at  large, 
and  their  more  general  intermingling,  there  is  a  tendency  at 
the  present  time  to  fads  in  food  and  diet  in  general  far  be- 
yond what  there  formerly  was.  It  will  be  well  for  physicians 
to  guard  their  patients  against  the  pursuit  of  these  fads  too 
zealously,  for  after  a  time  it  does  harm  to  the  individual. 
People  congregated  in  the  sanatoria  and  sanitaria  of  the  day 
are  prone  to  discuss  such  matters  in  connection  with  their 
general  infirmities,  and  to  carry  the  same  habits  out  into  the 
world  with  them  and  thus  generate  the  custom.  People  should 
depend  more  on  their  medical  advisers,  remembering  that 
"  he  who  is  his  own  lawyer  generally  has  a  fool  for  a  client," 
and  I  will  add  to  this  by  declaring  as  my  opinion  that  the 
amateur  doctor  is  usually  a  knave  or  a  fool,  or  worse. 

The  efifect  of  a  fanatical  pursuit  of  matters  pertaining  to 
one's  diet,  that  is  to  say,  of  the  diet  of  one  who  does  and 
should  in  a  measure  diet,  is  to  produce  a  real  fear  of  food, 
which  in  the  end  may  produce  a  genuine  disease,  a  genuine 
neurosis.  It  is  not  well  to  think  too  much  over  what  one  eats. 
We  must  observe  the  general  principles  of  diet  according  to 
our  condition  of  health,  as  I  have  endeavored  to  impress  upon 
my  readers  all  along,  but  after  these  hygienic  food  principles 
have  been  observed,  the  appetite  and  the  food  furnished  us 
may  be  more  or  less  trusted,  indeed  must  be  trusted,  to  retain 

251 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

our  proper  appreciation  of  food.  The  child  teaches  us  many 
things,  and  he  teaches  us  something  in  diet.  The  stomach  of 
the  child  is  delicate,  as  is  the  stomach  of  advancing  age,  yet 
one  reason  why  the  child  can  eat  and  digest  certain  things 
which  the  older  person  cannot  is  because  the  child  never  gives 
it  a  thought  after  swallowing,  whilst  the  older  person,  espe- 
cially the  one  who  has  fads  about  eating,  will  have  it  disagree 
with  him  because  he  thinks  about  it  and  expects  it  to  disagree 
and  give  him  discomfort.  The  lesson  to  be  learned  from  all 
this  is,  do  not  become  fanatical  in  matters  of  diet,  do  not 
make  them  a  matter  of  too  general  discussion,  and  rely  more 
upon  your  physician  than  you  do  upon  your  friend  who  has 
visited  all  the  great  health  resorts  of  Europe  and  America, 
and  who,  to  use  a  slang  expression,  "  knows  it  all."  Above 
all  things,  take  no  advice  from  newspapers,  quacks,  or  ama- 
teur doctors. 

Infantile  Scurvy. — Adult  scurvy  is  an  acquired  afebrile 
disease,  caused  probably  from  the  want  of  fresh  vegetables 
and  fruits,  and  from  too  much  salt,  from  bad  water  and  bad 
surroundings  in  general.  There  is  even  a  possibility  of  its 
being  an  infectious  disease,  caused  by  some  pathogenic  germ 
as  yet  undiscovered-  The  salt  used  in  preserving  the  animal 
foods  of  soldiers  and  sailors  and  others  may  be  a  factor  in 
causation  by  extracting  the  native  salts  of  meats  along  with 
the  water,  and  by  its  well-known  antiseptic  action  changing 
in  some  way  the  meat-fibres.  The  chief  symptoms  are  debil- 
ity, rapid  heart  action,  iron  hardness  of  the  muscles,  especially 
of  the  gastrocnemii,  hemorrhages  deep-seated  and  superficial, 
spongy  and  bleeding  gums,  loose  teeth,  and  the  "  greenery- 
yallery"  look  of  Gilbert's  young  man  in  "  Patience." 

An  entirely  different  trouble  is  infantile  scurvy,  scurvy 
rickets,  Barlow's  disease,  periosteal  cachexia.  This  is  a  most 
interesting  disease,  but  recently  recognized,  and  especially 
increased,  it  is  supposed,  since  the  advent  of  the  various  pro- 
prietary infant-foods  now  so  common.  Professor  Roberts 
Bartholow  has  given  the  best  account  of  this  trouble,  and  by 
so  doing  has  again  made  good  his  reputation  as  an  original 

252 


FORTY    YKARS    IN    THl-:    MKDICAI.    I'RoFlCSSION 

investi|:^"at()r.  Infantile  scurvy  was  really  (|uite  well  described 
by  tlie  late  Dr.  John  S.  Parry,  one  of  the  l)rif^htest  men  of  his 
day,  who  died  prematurely  of  tuberculosis  in  1876;  but  Parry 
wrote  only  of  infantile  rickets,  and  unknowingly  gave  us  a 
good  account  of  the  disease  we  are  Cf)nsidering.  It  is  usually 
confined  to  the  first  six  years  of  life,  but  has  been  seen  as  late 
as  nine  years  and  as  early  as  four  weeks.  It  comes  more  fre- 
quently to  those  children  who  have  a  tendency  from  birth  to 
lack  of  normal  bone-structure,  and  to  those  early  deprivefl  of 
maternal  nourishment  and  fed  on  artificial  infant- foods  and 
sterilized  milk.  Pasteurized  milk  is  less  apt  to  be  a  factor  in 
its  production,  but  remember,  it  has  caused  it.  It  has  even 
been  seen  in  children  fed  absolutely  from  their  own  mother, 
yet  these  cases  are  very  rare.  It  is  probably  a  combination  of 
scurvy  and  rickets,  or  rather,  probably  children  predisposed 
to  rickets  are  more  predisposed  to  scurvy.  The  symptoms  are 
numerous,  l)ut  the  distinctive  symptoms  are  pain  on  motion, 
which  is  very  acute,  simulating  rheumatism,  or  even  paralysis, 
and  the  characteristic  spongy  gums,  there  often  being  ulcera- 
tive stomatitis,  but  rarely,  if  ever,  gangrene  of  the  mouth. 

When  connected  with  the  Philadelphia  Hospital,  Blockley, 
years  ago,  I  probably  saw  cases  of  infantile  scurvy  and  made 
a  study  of  these  infantile  mouth  diseases.  Among  the  symp- 
toms are  increase  of  blood-pressure,  causing  polyuria  and 
restlessness  of  the  individual ;  there  is  often  periostitis  about 
the  joints,  particularly  of  the  tibial,  and  a  general  hyperaes- 
thesia  of  the  whole  body.  The  pains  are  supposed  to  be  caused 
by  hemorrhages  beneath  the  periosteum,  and  hemorrhage 
causes  much  of  the  gum  trouble.  There  may  be  h'emorrhages 
under  the  skin  in  various  places,  there  may  be  "  black  eye" 
caused  by  hemorrhage  into  the  orbit,  and  there  may  be  hemor- 
rhage from  the  nose,  bladder,  and  bowels.  An?emia  and 
marasmus  may  accompany  infantile  scurvy,  without  being 
the  cause,  or  in  some  cases  the  child  may  appear  to  be  thriving, 
and  yet  the  leg-pains,  the  general  hypersesthesia,  and  the  con- 
dition of  the  gums  make  the  diagnosis  plain  or  give  us  sutli- 
cient  hints  to  get  at  the  trouble.     As  a  rule,  the  child  has  a 

253 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

dusky,  sickly  look,  and  there  are  frequent  swellings  of  the 
joints- and  soft  parts.  Fever  is  seldom  present,  but  has  been 
recorded  as  high  as  105°  F.  There  are  other  important  points 
in  the  diagnosis  as  distinguishing  it  from  summer  complaint, 
so  common  in  the  Middle  and  Northern  States  and  much  less 
common  in  the  South  and  the  West.  Neither  vomiting  nor 
constipation  nor  diarrhoea  are  constant  symptoms,  but  I  think, 
most  assuredly,  cholera  infantum  as  we  see  it  predisposes  to 
infantile  scurvy,  and,  as  a  rule,  only  bottle-fed  babies  have 
cholera  infantum,  and,  as  a  rule,  only  bottle-fed  babies  have 
infantile  scurvy.  The  report  of  Drs.  J.  P.  Crozer  Griffith, 
Charles  G.  Jennings,  and  John  Lovett  Morse  to  the  American 
Pediatric  Society,  as  published  in  the  Philadelphia  Medical 
Journal,  shows  that  about  an  equal  number  of  males  and  fe- 
males have  the  disease.  A  majority  of  the  cases  developed 
from  the  seventh  to  the  fourteenth  month,  and  a  large  major- 
ity of  the  cases  were  among  the  well-to-do.  I  should  draw 
from  this  that  it  was  due  chiefly  to  artificial  feeding,  for  the 
best  mothers  for  nursing  are  not,  as  a  rule,  among  the  higher 
classes. 

Now,  as  to  the  causes  of  the  trouble.  Whilst  we  must 
frankly  admit  that  infantile  scurvy  has  been  seen  in  the  child 
who  has  never  been  fed  otherwise  than  from  its  mother's 
breast,  this  milk  coming  up  to  the  average  standard  of  human 
milk,  and  whilst  we  must  equally  frankly  admit  that  a  satis- 
factory explanation  of  the  etiology  of  infantile  scurvy  has 
not  yet  been  given,  yet  I  confess,  to  me  the  most  important 
etiologic  factor  is  the  use  of  the  common  every-day  baby- 
foods  sold  in  the  shops.  Next  comes  the  use  of  sterilized 
foods,  more  particularly  milk.  There  is  evidently  something 
in  the  cooking  of  foods,  of  destroying  all  life  in  them,  which 
has  something  to  do  with  causing  this  disease,  showing  that 
nutrition  in  general  may  be  affected  in  human  beings  by  lack 
of  at  least  some  of  the  natural  elements  of  food  in  a  raw  and 
natural  state  when  these  natural  elements  are  driven  out  by 
cooking  or  sterilizing.  Probably  sixty  per  cent,  of  the  cases 
have  been  caused  by  proprietary  infant-foods,  leaving  forty 

254 


FOR'J'Y    Yi'ARS    IN    11 1 1-.    MIODICAI.    i'R(;FIiSSION 

per  cent,  to  other  causes.  It  may  be  well  to  state  here  that 
from  the  reports  family  history  has  not  been  an  important 
factor  ill  the  disease.  In  ;l  large  majority  of  the  reports  re- 
ceived by  the  physicians  before  mentioned,  those  making  the 
reports  thought  the  nature  of  the  food  used  caused  the  trou- 
1)le.  In  406  cases  the  food  used  when  the  scurvy  developed 
was  as  follows:  Breast  milk  alone,  10  cases;  raw  milk  and 
amylaceae,  1  case;  sterilized  milk  with  amylacea;,  i  case; 
total,  12.  Raw  milk  alone,  4;  with  breast  milk  and  amylaceae, 
I ;  total,  5.  Milk  alone,  nothing  said  about  heating,  8;  pep- 
tonized, 4;  with  amylaceae,  4;  total,  16.  Sterilized  milk 
alone,  68 ;  together  with  proprietary  foods,  2 1 ;  with  amy- 
laceae, 8;  peptonized,  10;  total,  107.  Pasteurized  milk  alone, 
16;  with  proprietary  foods,  2 ;  with  amylaceae,  i ;  peptonized, 
i;  total,  20.  Peptonized  milk,  3 ;  sterilized,  8;  Pasteurized, 
I ;  with  proprietary  foods,  i ;  with  amylaceae,  i ;  total.  14. 
Amylaceous  food  (not  proprietary)  alone,  6;  with  breast 
milk,  3 ;  with  milk,  5 ;  with  sterilized  milk,  8 ;  with  Pateur- 
ized  milk,  i ;  with  peptonized  milk,  i ;  total,  24  (nine  of  these 
were  oatmeal).  Table  food,  nothing  else  mentioned,  11; 
with  condensed  milk,  i ;  total,  12.  Mellin's  food,  nothing 
further  stated,  42 ;  Mellin's  food  and  condensed  milk,  22 ; 
with  sterilized  milk,  16;  with  Pasteurized  milk,  2;  with 
other  proprietary  food,  i ;  total,  83.  Malted  milk,  nothing 
further  stated,  44 ;  with  cream  and  malted  milk,  i  ;  with  amy- 
laceae, I ;  with  other  proprietary  food,  2 ;  total,  48.  Con- 
densed milk  alone,  32 ;  with  milk,  i ;  with  cream,  i  :  with 
other  proprietary  foods,  3 ;  with  table-food,  i  ;  total,  38. 
Reed  and  Carnrick's  soluble  food,  13.  Imperial  Granum,  6. 
Liebig's  food  alone,  i ;  with  condensed  milk,  i ;  total,  2. 
Lactated  food  alone,  3 ;  with  condensed  milk,  i  ;  total.  4. 
Nestle's  food  alone,  i :  with  sterilized  peptonized  milk,  i  ; 
total,  2. 

In  a  number  of  reports  proprietary  foods  were  given  with 
no  name,  making  sixty  per  cent,  of  the  cases  fed  on  proprie- 
tary foods.  The  farther  away  the  diet  of  the  child  is  from 
mother's    milk,    the    more    likely    is    it    to    develop    scurvy. 

255 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Whether  it  is  an  infections  disease  or  not  we  cannot  yet 
say,  bnt  in  the  end  some  pathogenic  germ  may  show  np  ex- 
plaining all  of  the  symptoms  and  thns  giving  ns  a  rational 
cause  for  the  trouble.  The  mortality  is  not  great.  Twenty- 
nine  reported  cases  out  of  three  hundred  and  seventy-nine 
died ;  two  of  these,  at  least,  died  of  other  diseases,  leaving 
only  twenty-seven  deaths  due  to  scurvy.  The  autopsies 
showed  the  following  lesions  :  Hemorrhagic  spots  on  the  peri- 
cardium and  on  the  liver  surface,  subperiosteal  hemorrhages 
of  long  bones,  subpleural  hemorrhages,  separation  of  the 
lower  epiphysis  from  the  shaft  of  the  femur,  bronchopneu- 
monia, hemorrhage  into  the  muscles  of  the  thigh,  swelling 
of  knee  and  both  ankles,  exudative  nephritis,  the  right  leg 
from  the  knee  to  the  ankle  stuffed  with  a  puffy  mass  replacing 
the  normal  tissue,  separation  of  both  bones  one  inch  above 
the  ankle,  blood-serum  in  the  pleural  cavity,  perforating  ulcer 
of  the  stomach,  tuberculosis  of  the  peritoneum. 

It  may  be  proper  to  state  here  that  Dr.  Augustus  Caille,  of 
New  York,  presented  a  minority  report,  being  on  the  com- 
mittee with  Drs.  Griffith,  Jennings,  and  Morse.  Dr.  Caille 
believes  infantile  scurvy  to  be  a  chronic  ptomaine  poisoning 
due  to  the  absorption  of  toxines.  It  follows  the  prolonged  use 
of  improper  foods,  and  abnormal  intestinal  fermentation  is  a 
predisposing  factor.  Sterilizing,  Pasteurizing,  or  cooking  of 
milk-food  is  not  per  sc  responsible  for  the  scurvy  condition. 
A  change  of  food  and  the  administration  of  fruit- juice  and 
treatment  of  any  underlying  cause  is  the  rational  therapeutic 
procedure  in  scurvy.  Here  Dr.  Caille  gives  a  definite  cause, 
which  differs  from  others,  among  them  Dr.  David  Bovaird, 
of  New  York  City,  who  has  given  us  a  good  article  on  this 
disease  in  the  Philadelphia  Medical  Journal  for  August  20, 
1898,  and  from  which  I  have  now  and  then  quoted  in  this 
article.  Dr.  Bovaird  concludes  as  follows :  "  Sterilized  milk 
evidently  does  cause  infantile  scurvy."  He  says  the  evidence 
presented  in  his  article  is  not  conclusive,  but  it  renders  it 
highly  probable  that  persistent  sterilization  of  the  food  by 
boiling  may  produce  scurvy.     It  must  even  be  admitted  that 

256 


FORTY    YEARS    TN    TTTK    MEDICAI.    i'KOl'KSSION 

scurvy  may  ])c  developed  in  luirslinji^s.  The  admission  of  this 
proposition  carries  with  it  a  frank  confession  of  inability  to 
accept  as  adequate  any  theory  of  the  causation  of  scurvy  thus 
far  advanced.  Practically  the  only  theory  that  has  of  late 
commanded  any  general  support  is  that  which  attributerl  the 
production  of  scurvy  to  the  absence  of  some  vital  principle 
from  the  food,  the  life  of  the  food  being  destroyed  by  some 
process  of  preparation.  If,  now,  we  admit  the  possibility  of 
infantile  scurvy  developing  in  nurslings,  we  must  abandon 
even  this  hazy  attempt  at  the  elucidation  of  the  problem,  and 
frankly  confess  that  a  satisfactory  explanation  of  the  etiology 
of  infantile  scurvy  is  still  to  be  sought. 

Personally  I  think  something  may  be  gained  in  getting  at 
the  etiology  of  this  disease  through  thorough  and  systematic 
examinations  of  the  urine.  Dr.  Churchill,  of  Chicago,  among 
others,  has  given  us  some  information  useful  as  to  the  renal 
secretion  of  children  in  general,  and  this  may  serve  as  a  com- 
parison in  clinical  studies  in  such  diseases  as  we  are  dis- 
cussing. According  to  Churchill's  observations,  infants  pass 
highly  concentrated  urine,  small  in  amount,  with  a  high  per- 
centage of  urea  and,  of  course,  high  specific  gravity.  The 
amount  of  urea  per  kilogram  of  weight  might  be  an  impor- 
tant point.  It  grew  less  towards  the  seventh  year,  when  the 
average  was  only  0.296.  At  three  years  the  average  was 
from  0.468  to  0.655.  Different  diets  may  give  different  re- 
sults, and  surely  will,  and  may  lead  us  to  detect  the  trouble 
through  the  amount  of  nitrogenous  and  other  waste  of  the 
system,  and  thus  check  it  before  serious  harm  comes  to  the 
individual. 

Treatment. — If  the  child  is  weak  and  debilitated  see  that 
it  has  proper  support  by  stimulants  and  by  the  administra- 
tion of  the  salts  of  potash.  The  best  I  know  of  -and  which 
has  served  me  best  is  the  bitartrate  of  potash,  cream  of  tartar. 
Give  this  diluted  with  a  large  amount  of  water,  both  to  get 
the  potash  and  the  water,  which  is  of  great  importance. 
Whatever  the  child  has  been  feeding  on,  change  that  diet. 
Stop  proprietary  and  prepared  amylaceous  foods.  Give  raw 
17  257 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

cow's  milk,  keenly  watching  its  source.  If  this  should  not 
agree,  Pasteurize  it  only,  do  not  sterilize  it;  give  beef-juice 
from  fresh  beef  and  no  other,  that  is  to  say,  no  prepared  beef- 
juices,  as  they  may  be  as  bad  as  proprietary  amylaceous  foods. 
Orange-juice  from  fresh  oranges  is  best  because  it  takes  up 
the  basic  salts  during  digestion  and  thus  serves  its  good  pur- 
pose of  supplying  potash  and  such  salts.  Fresh,  ripe,  soft 
peaches  are  a  food  par  excellence  for  these  little  sufferers. 

I  had  a  little  patient  which  was  brought  to  me  in  very  hot 
weather,  supposed  to  be  a  sufferer  from  cholera  infantum. 
Much  to  the  horror  of  his  friends,  I  ordered  him  all  the  soft, 
ripe  peaches  he  could  eat.  He  took  six  and  eight  every 
twenty-four  hours,  and  the  improvement  that  child  made 
was  a  revelation.  If  you  cannot  get  oranges  or  peaches,  get 
apples,  pears,  strawberries,  plums,  and  any  fruits  in  market. 
There  are  always  some  kinds.  Always  choose  the  softest  and 
juiciest. 

Just  here  remember  one  thing,  the  possibility  of  developing 
such  a  trouble  as  infantile  scurvy  in  your  typhoid  fever  and 
other  tedious  cases  from  a  prolonged  use  of  sterilized  milk 
and  such  food-stuffs.  I  say  keep  it  in  mind,  if  your  patient 
from  some  hidden  cause  ceases  to  advance  properly  towards 
convalescence.  Remember,  above  all  things,  all  the  food  or- 
dered must  have  the  element  of  freshness.  Canned  peaches 
will  not  do;  canned  beef-juice  will  not  do.  In  canning  we 
sterilize  first,  we  destroy  all  bacteria,  and  all  the  elements  of 
freshness  are  taken  from  the  food,  thence  such  food  is  scurvy 
breeding.  So  it  is  with  the  preserved  fruit-juices:  they  are 
not  fresh,  hence  are  neither  food  nor  medicine  for  infantile 
scurvy.  Keep  these  principles  in  mind,  and  you  will  soon 
cure  all  of  your  patients.  Heed  them  not,  and  you  will  prob- 
ably lose  both  your  patients  and  your  professional  reputation. 

In  "  Paediatrics"  Dr.  Cotton  suggests  the  following  as  the 
essentials  of  a  good  baby-food :  ( i )  Does  this  food  contain 
all  the  constituents  in  about  the  same  proportions  as  they  are 
found  in  mother's  milk  ?  ( 2 )  Can  this  food  be  administered 
in  a  form  suitable  to  the  physiological  requirements  of  the  in- 

258 


FORTY    YEARS    IN    Tfll-:    MEDICAL    PRr)FESSION 

fant's  (lif^estion?  (3)  Can  it  be  .i^iven  in  cjnantities  aflapted 
to  the  capacity  of  the  infant's  stomach?  (4.)  Does  it  possess 
the  antiscorbutic  property,  or  has  that  been  destroyed  by  cook- 
"iR?  (5)  '•'^  t^'c  food  wliolly  or  ])artly  of  animal  origin? 
(6)    Is  it  free  from  pathogenic  micro-organisms? 

Concerning  Milk. — Ex])erience  teaches  mc  the  great  impor- 
tance of  physicians  Icnovving  much  a1)ouL  niilk,  lliat  great 
staple  article  of  diet  for  all,  and  especially  for  the  very  young 
and  for  the  very  old.  A  physician  should  be  able  to  advise 
housekeepers  and  nurses  on  all  points  concerning  its  compo- 
sition already  spoken  of,  of  the  different  grades,  of  the  roguery 
of  dealers  as  practised,  of  the  tests  to  detect  such  deceit,  of 
the  proper  methods  of  keeping  and  marketing  the  article ;  in 
fact,  all  about  it.  The  details  I  am  about  to  give  will  be  found 
best  set  forth  in  "  Farmers'  Bulletin,"  No.  42,  United  States 
Department  of  Agriculture,  by  R.  A.  Pearson,  B.S.,  As- 
sistant Chief,  Dairy  Division,  Bureau  of  Animal  Industry. 
Ten  years  ago  the  value  of  the  milch  cows  in  the  United 
States  was  three  hundred  and  seventy  millions  of  dollars. 
This  shows  the  importance  of  the  industry.  There  is  a  cow 
in  this  country  to  every  four  of  its  inhabitants,  but  much  of 
the  product  goes  abroad  as  cheese  and  butter  and  condensed 
milk.  Americans  do  not  appreciate  the  product  of  the  cow 
as  much  as  they  do  in  most  parts  of  Europe  where  they  use 
more  milk  per  capita  than  we  do  here.  One  reason  doubtless 
is,  we  use  more  meat  here.  The  average  consumption  of  milk 
in  the  United  States  is  one  half-pint  per  day  to  each  inhabi- 
tant. Milk  to  the  ordinary  observer  appears  to  be  a  perfect 
solution,  and  is  bought  and  sold  by  liquid  measure.  Under 
the  microscope  it  is  seen  to  consist  of  a  clear,  transparent 
fluid  containing  many  minute  globules  of  various  sizes.  The 
fluid  part,  called  the  milk  serum,  consists  of  water  and  all  of 
the  other  constituents  except  fat,  and  all  of  these  constituents 
except  the  fat  are  in  solution.  The  globules  are  little  bodies 
of  pure  fat  in  the  serum  and  not  dissolved.  They  are  semi- 
solids and  form  with  the  serum  an  emulsion,  and  therefore 
milk  as  we  see  it  is  a  true  emulsion.    The  solid  constituents  of 

259 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 


the  serum  are  sugar  and  casein  mostly.  Albumin  and  min- 
eral matter  are  present  in  small  quantity,  and  there  is  also  a 
little  fibrin.  There  is  more  sugar  in  milk  than  any  other 
solid,  and  this  when  separated  is  the  well-known  sugar  of 
milk.  It  is  not  so  sweet  as  cane-sugar.  When  milk  sours  it 
is  the  sugar  that  undergoes  the  greatest  change.  The  casein 
and  albumin  of  milk  are  its  nitrogenous  constituents,  and  are 
comparable  to  the  white  of  egg.  Acid  or  rennet  causes  ca- 
sein to  coagulate,  forming  curd,  and  as  such  this  forms  one- 
fourth  of  cheese.  The  mineral  matter  is  the  ash  when  burned, 
and  consists  chiefly  of  phosphates  and  chlorides  of  soda,  pot- 
ash, and  lime.  Milk  may  be  compared  to  a  thin  syrup  with 
many  fatty  and  light  particles  floating  in  it.  Milk  is  sticky, 
and  this  retards  the  too  rapid  rise  of  the  cream  or  fat.  The 
fat  globules  are  very,  very  small.  A  single  drop  contains 
many  millions, — the  number  is  too  large  to  be  appreciated. 
The  globules  average  one-ten-thousandth  of  an  inch  in  diam- 
eter. The  Jersey  and  Guernsey  cows  have  the  largest  fat 
globules,  and  thus  their  cream  rises  more  readily  and  their 
skim-milk  is  poor.  The  larger  the  globule,  the  sooner  and 
easier  it  rises.  These  are  very  important  facts  for  physicians 
to  know.  One  hundred  pounds  of  good  milk  contain  87 
pounds  of  water,  4  pounds  of  fat,  5  pounds  of  milk-sugar,  3.3 
pounds  of  casein  and  albumin,  and  .7  pound  of  salts.  The 
solids  vary  in  milk  from  10  to  18  parts  in  100.  Here  is  the 
important  part  which  distinguishes  good  from  poor  milk. 


TOTAL 
SOLIDS. 


Showing  relative  parts  of  milk. 


Sugar. 

Fat. 

Casein. 

Ash. 

Most  of  the  States  have  a  standard  for  milk.  The  laws 
usually  require  from  three  to  three  and  one-half  per  cent,  of 
fat  and  from  nine  to  nine  and  one-half  per  cent,  of  "  solids 
not  fat."     When  we  speak  of  "  solids  not  fat,"  the  trade 

260 


FORTY    VI'.ARS    IN    T]\]:    MEDICAL    PROFESSION 

knows  this  to  mean  all  S(jli(ls  not  fat.  The  avcraj^e  law  then 
requires  at  least  twelve  to  thirteen  pounds  of  solids  to  every 
one  hundred  pounds  of  milk.  It  is  wrong  to  think  fat  the 
only  good  in  milk.  Skim-milk  has  great  value ;  the  casein 
and  albumin  of  skim-milk  are  very  cheap  forms  of  nitroge- 
nous food.  There  is  one  thing  true,  though. — the  more  fat 
in  milk,  the  more  "  solids  not  fat"  there  arc.  Jersey  and 
Guernsey  cows  produce  the  best  milk  for  cream,  but  not  for 
use  as  milk.  Durham  and  Ayrshire  cows  are  better  cows  for 
milk  for  use  as  milk.  The  Holstein  cows  give  the  largest 
quantity  of  milk ;  some  of  them  give  good  milk,  whilst  the 
milk  of  others  is  blue  and  poor.  The  feed  of  the  cow  influ- 
ences some,  but  the  breed  more.  The  feed  influences  quantity 
more  than  quality. 

Remember  that  the  colostrum,  the  first  milk  given  by  a  cow 
after  calving,  contains  much  albuminoids  and  is  laxative,  and 
is  not  fit  for  human  food.  Nature  designs  it  for  the  calf 
alone.  The  albumin  and  casein  in  colostrum  may  form  fifteen 
per  cent,  of  the  milk.  The  sugar  percentage  is  low.  the  fat 
normal.  In  a  week  after  calving  the  cow  produces  natural 
milk.  The  dairyman  in  his  greed  does  not  usually  wait  this 
long,  but  he  should  be  made  by  law  to  wait  at  least  seven  days. 

The  percentage  of  fat  in  milk  varies  from  day  to  day  in  the 
same  cow,  and  any  variation  in  her  food  does  not  account  for 
it,  and  this  and  other  such  causes  make  it  appear  better  to 
use  for  children's  food  the  milk  from  a  healthy  herd  rather 
than  from  one  healthy  cow.  The  longer  a  cow  milks  from 
her  calving,  the  more  solids  there  are  in  her  milk,  and  the  less 
easily  the  cream  rises.  A  cow  can  be  milked  ten  months  in 
each  year,  and  should  go  dry  two  months. 

The  term  "  extend  the  milk"  is  used  in  the  trade  to  denote 
adulterating  the  milk  by  different  methods.  ^Nlilk  is  a  cheap 
article  of  food  at  a  fair  price,  and  cheap  milk  cannot,  as  a  rule, 
be  good  milk.  When  the  dealer  has  delivered  you  good  milk, 
remember  it  is  easily  contaminated  after  you  have  received 
it.  If  dust  settles  on  it,  or  flies  or  other  insects  have  access 
to  it,  or  if  placed  in  a  badly  ventilated  cellar,  or  in  a  refriger- 

261 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

ator  with  other  foods,  or  in  a  place  too  warm,  it  goes  to  the 
bad  in  a  few  hours.  To  have  milk  in  proper  condition  for 
food  it  should  be  kept  in  an  apartment  absolutely  to  itself, 
and  at  a  temperature  of  as  near  50°  F.  as  possible.  Remem- 
ber well  this  injunction :  there  is  only  one  class  of  vessels  fit 
to  keep  milk  in,  and  these  are  glass  or  porcelain  vessels.  Use 
no  tin,  no  iron,  no  patent  wares,  no  earthenware ;  use  only 
glass  or  porcelain.  I  wonder  the  trade  does  not  supply  glass 
or  porcelain  milk-pans  and  such  like  useful  articles. 

In  cities,  if  you  have  trouble  with  the  milk  furnished  your 
patients,  investigate  the  milk-man  and  the  servants,  and  see 
if  any  possible  connivance  may  be  going  on  between  them  or 
between  rival  dealers.  Thunder-storms,  impurities,  warm 
temperature,  and  other  conditions  may  change  milk,  but  these 
are  indirect  causes  only ;  bacteria  are  the  great  causes.  There 
are  various  bacteria  in  milk,  and  various  fermentations  which 
go  on  in  it.  Milk  becomes  blue,  bitter,  slimy,  ropy,  according 
to  the  species  of  bacteria,  etc.,  present.  Any  milk  with  sedi- 
ment is  suspicious.  Where  you  have  dirt  you  have  micro- 
organisms. Those  who  attend  to  cows  and  milk  in  all  of  its 
phases  should  be  clean,  morally  and  physically,  and  healthy. 
It  is  of  equal  importance  that  the  cows  should  be  healthy. 
Discard  all  milk  of  an  unnatural  appearance  or  odor.  Bac- 
terial action  may  cause  odors,  as  well  as  garlic  and  such  pun- 
gent vegetables.  Watch  for  the  adulteration  of  milk.  Water 
may  be  used,  part  of  the  cream  may  be  extracted,  or  it  may 
be  blended,  good  with  bad,  and  very  bad.  Impure  water  used 
in  adulteration  may  bring  pathogenic  germs  to  the  milk;  do 
not  forget  this.  Even  rinsing  the  cans  in  impure  water  may 
distribute  pathogenic  germs  on  the  milk  route.  All  milk-cans 
and  bottles  should  be  absolutely  sterilized  before  each  time  of 
use.  Prohibit  as  physicians  the  use  of  artificial  preserva- 
tives in  milk.  Salicylic  acid,  boric  acid,  borax,  and  formal- 
dehyde are  used.  They  all  slow  digestion  even  in  small  doses, 
and  formaldehyde  interferes  with  the  digestion  of  albuminoids. 
All  of  these  remedies  should  be  used  as  remedies  under  care  of 
physicians,  not  in  trade  by  ignorant  venders  of  food-stuffs. 

262 


FORTY    YJ'.ARS    IN    Till':    iVli'UICAL    I'KOFICSSION 

Do  not  have  iiiill<  delivered  early  in  hot  weather  and  left 
exposed  to  the  sun,  as  is  often  done.  It  should  be  cold  when 
delivered,  and  at  a  temperature  of  50'  I'',  will  keep  sweet  and 
pure  for  thirty-six  to  forty  hours,  f.et  every  household  keep 
a  floating-  dairy  thermometer,  and  see  that  the  milk  is  kept  at 
about  50",  and  it  will  i^ive  no  (rouble  by  .souring  and  spoiling 
prematurely.  To  raise  cream  on  milk,  put  it  in  a  cold  place 
as  soon  as  received.  When  you  need  cream,  raise  the  tem|)era- 
ture  of  the  milk  to  100°,  and  then  lower  it  quickly  by  placing 
the  dish  in  cold  water.  To  do  this  the  milk  must  be  in  good 
condition,  or  it  will  sour  before  the  cream  rises.  The  cream 
rises  quicker  in  jars  than  in  pans. 

As  to  the  use  of  glass  milk-jars  for  delivering  milk.  There 
is  much  to  be  said  on  both  sides  here.  It  would  be  an  ideal 
method  if  we  could  depend  on  the  average  milk-dealer  to  ab- 
solutely sterilize  each  jar  each  time  before  delivering  milk  in 
it.  This  you  cannot  do.  The  jar  may  have  been  in  the  room 
of  a  typhoid  fever  patient,  or  even  of  a  small-pox  patient,  and 
you  may  be  the  next  customer  to  get  your  milk  in  it  loaded 
with  these  unwelcome  pathogenic  germs.  I  confess  I  rather 
oppose  these  milk-bottles  for  general  use,  but  there  are  milk- 
supply  people  whom  I  would  trust  to  distribute  milk  in  them, 
and  these  are  the  people  I  would  patronize,  and  be  willing  to 
pay  them  an  extra  price  for  their  product.  This  is  the  only 
way  I  know  of  to  get  pure  milk,  or  milk  any  way  near  pure. 
Each  bottle  should  be  sealed,  not  hermetically,  when  received, 
and  no  bottle  with  a  broken  seal  should  be  accepted. 

Detecting  Impure  Milk. — Here  is  a  matter  of  the  greatest 
importance  to  physicians,  and  how  many  know  about  it  as 
they  should  know  ?  Pure  milk  is  the  product  of  healthy,  well- 
fed  cows,  properly  handled  and  cared  for  by  individuals  mor- 
ally and  physically  clean  and  healthy.  Good  milk  should  have 
a  slightly  yellowish-white  color,  a  slight  odor,  if  any,  and 
should  have  a  distinctly  pure  taste,  as  Pearson  says.  When 
it  has  stood  quietly  for  several  hours,  cream  should  rise  natu- 
rally, and  if  the  separation  is  thorough  the  cream  should  be 
from  one-fifth  to  one-eighth  of  the  bulk.    No  sediment  should 

263 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

appear  at  the  bottom.  When  poured  from  a  tumbler  it  should 
cling  to  the  glass  some,  and  not  run  off  clear  like  water. 
Skim-milk  is  thin  and  bluish  in  color.  The  yellow  shade  of 
milk  is  due  to  the  fat,  but  color  is  not  a  safe  test,  as  some 
cows  give  rich  milk  of  a  lighter  color  than  milk  from  cows 
which  give  poor  milk ;  and  milk  may  be  artificially  colored. 

To  test  Milk. — First  get  a  fair  sample.  To  do  this  it  will 
not  be  fair  to  take  all  from  the  top  or  bottom  of  the  can ;  mix 
it  thoroughly  by  pouring  from  one  vessel  to  another  several 
times.  No  lumps  must  appear  on  the  surface.  If  small  lumps 
of  butter  are  floating  on  top  a  fair  sample  cannot  be  taken. 
Of  course,  if  you  want  a  thorough  test,  employ  a  chemist  and 
have  a  complete  analysis.  There  are  ordinary  tests,  sufficient 
for  the  practical  purposes  of  physicians. 

The  Creamometer  Test. — Creamometers,  as  well  as  lac- 
tometers and  all  ordinary  testing  apparatus,  may  be  purchased 
at  any  well-conducted  dairy-supply  house.  The  creamometer 
is  a  long,  graduated  glass  tube  with  the  zero  mark  near  the 
top.  It  gives  a  fair  test,  but  not  always  exact,  as  age  of  milk 
and  method  of  handling  it  may  make  some  difference.  Fill 
the  tube  to  the  zero  mark  with  milk  and  allow  it  to  stand  in  a 
cool  place  for  twenty-four  hours.  Warm  the  milk  to  ioo°  F. 
and  set  the  tube  in  cold  water  to  bury  the  cream,  or  fill  the 
tube  with  half  milk  and  half  warm  water,  which  raises  the 
temperature  and  reduces  the  viscosity;  now  only  half  as 
much  cream  will  appear  as  you  are  to  give  the  milk  credit  for, 
on  account  of  the  water  used,  so  double  the  per  cent,  shown 
and  you  get  the  true  per  cent.  If  the  milk  does  not  vary  from 
day  to  day  in  the  amount  of  cream,  it  shows  you  are  getting 
milk  of  regular  quality.  In  this  test  you  also  have  good  op- 
portunity to  look  for  sediment.    Always  use  the  tube  quietly. 

The  Lactometer. — Milk  is  heavier  than  water.  Its  specific 
gravity  varies  from  1029  to  1033,  and  a  departure  from  this 
standard,  as  to  skimming  or  watering,  can  be  measured  by 
this  instrument,  which  every  physician  should  own  and  every 
household  should  have  at  hand.  The  Quevenne  lactometer  is 
one  of  the  best,  and  has  a  thermometer  combined.     It  can  be 

264 


FORTY    YEARS    IN    Til  I'.    MIChlCA!,    I'ROFKSSION 

purchased  at  any  good  dairy-supply  house,  willi  full  (hrec- 
tions  for  use.  These  instruments  can  only  show  specific  grav- 
ity. If  cream  has  been  removed  which  is  lighter  than  whole 
milk,  the  specific  gravity  is  increased,  and  if  water  has  been 
added,  the  specific  gravity  is  of  course  lower.  Now,  if  we 
get  a  high  specific  gravity,  we  suspect  .skimming,  and  if  a 
low  specific  gravity  watering. 

There  is  also  another  test,  which  combines  mathematical 
formulae  in  its'carrying  out, — the  Babcock  fat  test.  This  is 
a  reliable  test  for  the  fat  of  milk,  ,-md  is  much  used  by  cream- 
eries and  other  houses  using  milk  and  cream  commercially. 
The  milk  is  centrifuged,  if  1  may  be  allowed  to  coin  the  word. 
Only  about  a  tablespoonful  is  required,  and  fifteen  minutes 
sufifices  for  the  test.  The  instrument  can  be  purchased  of 
dealers  for  a  few  dollars,  with  full  directions,  and  is  simple 
and  easy  in  its  operation. 

TJic  Acid  Test. — Professor  Farrington's  acid  test  is  simple, 
and  should  be  recommended  by  physicians  to  those  engaged 
in  the  care  of  children.  Acid  commences  to  form  in  milk  soon 
after  it  comes  from  the  cow.  This  test  will  show  if  it  is  too 
near  the  souring-point  for  use  for  delicate  stomachs.  Tablets 
containing  a  definite  amount  of  alkali,  caustic,  potash,  or  soda, 
say,  are  dissolved  in  water  and  added  to  a  definite  amount  of 
milk.  The  tablets  contain  a  little  phenolphthalein,  which  is 
colorless  in  acid  solution  and  pink  in  alkaline  solution.  A 
solution  of  these  tablets  is  slowly  added  to  the  milk,  and  the 
mixture  is  stirred  until  it  becomes  pink.  It  is  known  now 
that  enough  alkali  has  been  added  to  neutralize  the  acid  in 
the  measured  amount  of  milk,  and  the  amount  of  solution  re- 
quired indicates  the  acidity  of  the  milk.  Fresh  milk  has  little 
acid,  and  turns  pink  on  addition  of  a  small  amount  of  alkali, 
while  milk  nearly  sour  requires  more  alkali  to  turn  it  pink. 
These  Farrington  tablets  can  be  found  in  the  shops,  with  full 
directions  for  use,  and  every  house  should  have  them  on  hand. 
They  are  made  of  definite  strength.  Should  a  solution  of  two 
tablets  turn  one  ounce  of  milk  pink,  that  milk  should  keep 
from  twenty-four  to  thirty-six  hours  with  proper  care.     If 

26s 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

the  milk  remain  white  after  the  addition,  it  will  soon  turn 
sour.    ■ 

Test  for  Colosfntni. — If  milk  coagulates  on  boiling,  it 
shows  the  probable  presence  of  colostrum,  because  colostrum 
is  highly  albuminous,  and  here  it  is  the  albumin  wdiich  has 
coagulated.  The  cow  furnishing  this  milk  has  been  milked 
too  soon  after  calving.  The  calf,  not  the  baby,  should  get 
this  milk.  It  will  probably  give  the  baby  diarrhoea,  among 
other  troubles.  We  have  no  reliable  test  for  micro-organisms 
but  the  microscope,  and  this  should  be  brought  to  bear  when 
necessity  points  in  that  direction.  Percentage  milk  I  have 
spoken  of  before  whilst  speaking  of  diet  in  general,  and  I 
trust  its  use  may  grow  rapidly,  for  it  is  capable  of  being  put 
to  great  therapeutic  advantage  under  many  and  various  con- 
ditions. 

I  append  Pearson's  rules,  to  follow  in  choosing  your  milk- 
man and  milk-supply.  He  should  show  a  quarterly  certificate 
from  a  veterinarian  of  good  standing, — a  licensed  veterina- 
rian, by  all  means, — stating  that  after  a  careful  examination 
of  his  cows — if  he  is  a  producer  as  well  as  a  vender ;  if  only  a 
vender,  then  from  the  herds  supplying  him  with  milk — they 
were  all  found  to  be  healthy;  that  if  there  were  any  doubt- 
ful cows,  they  had  been  removed;  that  the  quality  of  the 
feed  and  water,  the  sanitary  conditions  of  the  stables  and  sur- 
roundings, and  the  health  of  the  employees  were  approved. 
If  you  believe  your  milk-man  is  honest,  let  him  know  it.  If 
not  honest,  get  another  at  once. 

Pearson  recommends  consumers  to  visit  the  dairy  farms 
and  general  sources  of  supply  of  their  milk,  as  apt  to  do  good. 
On  a  well-conducted  dairy  farm  he  would  expect  the  visitor 
to  see  a  roomy,  de^n,  dry,  light,  and  well-ventilated  stable  or 
cow-house.  To  produce  good  milk,  cows  must  be  comforta- 
ble, and  these  conditions  not  only  add  to  their  comfort,  but 
are  absolutely  necessary  to  keep  them  in  the  best  health.  Let 
me  add  here,  do  not  make  them  too  comfortable;  do  not 
change  their  natural  environment  too  radically.  Give  cows 
palatial  stables,  Axminster  carpets,  and  modern  heating  ap- 

266 


FORTY    YI'lAKS    IN    'lllh:    M  l.l  M(  :.\  L    l'KOI''l':.SSfON 

pliaiiccs,  ;iii(l  ^-ou  will  (Icvclop  lubcrculosis  in  eighty  j^cr  cent, 
of  tliem  in  a  twelvemonth.  Tlie  cow.s  must  be  healthy,  well 
fed,  and  contcntccl.  An  a1)nndan(c  (»f  jinrc  water  twice  a  day 
I  would  add  here  after  each  milkinj^',  when  the  system  has 
been  drained,  h'ced  should  be  of  j^oorl  fjuality.  The  grain 
and  coarse  fodder  should  be  free  from  dirt,  decay,  or  musty 
condition.  A  spirit  of  kindness  tcnvards  the  stock  and  gen- 
tleness of  the  animals  themselves  is  necessary,  as  well  as  pro- 
vision for  washing  and  sterilizing  all  utensils  which  come  in 
contact  with  milk. 

Provision  for  straining,  aerating,  and  cooling  the  milk  in 
a  clean  atmosphere,  free  from  stable  and  other  odors,  is  ab.so- 
lutely  essential.  This  treatment  should  take  place  immedi- 
ately after  the  milk  is  drawn  from  each  cow.  Facilities  for 
storing  the  milk  and  keeping  it  cold  must  be  at  hand.  Espe- 
cially great  cleanliness  in  regard  to  everything  connected  with 
the  dairy  slKuild  be  observed.  The  atmosphere  of  the  stable 
should  be  pure  and  free  from  dust  when  milking  is  being 
done.  Employees  should  carefully  wipe  the  udders  and  wash 
their  hands  before  milking,  and  should  be  in  clean  clothes. 
Whitewash  is  a  good  disinfectant,  and  should  be  seen  in 
many  more  stables;  and  land  plaster  (sulphate  of  lime) 
should  be  sprinkled  about  to  absorb  moisture  and  odors.  The 
cow  should  stand  on  clean  litter  only.  If  the  milk  is  handled 
through  a  store,  the  building  should  be  kept  scrupulously 
clean,  with  no  dust  or  dirt  in  the  milk-room.  There  should 
be  provision  for  keeping  the  milk  cold  when  stored,  and  appa- 
ratus for  sterilizing  utensils  after  washing. 

Pearson  suggests,  as  improvements  in  the  business,  that 
graded  milk  be  sold,  graded  as  to  its  fat  test  particularly.  Let 
the  people  learn  there  is  as  much  difference  in  milk  as  there  is 
between  the  better  and  coarser  cuts  of  beef.  This  is  all  right. 
Let  us  think  of  milk  not  as  milk  in  the  abstract,  but  as  to  its 
composition,  and  that  when  we  buy  it  we  pay  for  what  we  get, 
knowing  what  we  get.  knowing  there  are  high-priced  and 
low-priced  milks.  Such  methods  are  followed  in  France  and 
Germany.     Doctors  should  know  all  about  such  things,  not 

267 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

ouly  as  to  milk,  but  all  about  marketing  in  general  as  to  the 
cuts  of  beef,  mutton,  and  veal,  how  to  judge  poultr}'-  and 
game  and  fish  and  vegetables  and  fruits ;  in  fact,  all  domestic 
supplies ;  and  he  should  know  how  to  prepare  them  for  cook- 
ing and  how  to  cook  them,  too.  The  milk-supply  should  be 
rigidly  inspected  in  all  communities,  and  derelictions  should 
be  punished  by  radical  laws  enforced  without  fear  or  favor. 
Such  laws  are  necessary  to  the  well-being  of  society,  and  are 
not  by  any  means  sumptuary,  and  do  not  interfere,  when 
properly  looked  at,  with  the  liberty  of  the  individual.  Even 
if  they  do,  the  liberty  of  the  individual  should  not  stand  in  the 
way  of  anything  which  brings  death  and  destruction  to  com- 
munities. 

Pearson  suggests  that  milk-carts  carry  graded  milk,  put- 
ting different  grades  in  different  cans,  plainly  marked  with 
their  grade,  and  with  separate  taps  on  the  outside  of  the  cart 
leading  to  each  can.  Purchasers  would  then  see  what  they 
were  buying,  and  know  exactly  what  they  were  paying  for  it. 
He  suggests  the  following  grades.  The  grades  of  milk  should 
be  numbered  with  the  whole  numbers  nearest  to  the  percentage 
of  fat  contents.  Thus  a  separator  skim-milk  with  but  a  trace 
of  fat  would  be  o ;  skim-milk,  with  from  one-half  to  one  and 
one-half  per  cent,  fat,  would  be  i ;  and  so  on.  Whole  milk 
would  be  of  three  grades,  3,  4,  and  5,  and  extra  rich  and  for- 
tified milk,  to  which  cream  has  been  added,  would  be  9  or  10. 
Cream  would  run  from  13  to  50.  No  more  grades  of  milk 
or  cream  need  be  carried  than  is  the  custom  now,  but  each 
should  be  marked  with  its  appropriate  number.  While  the 
idea  of  the  percentage  of  fat  thus  indicated  might  not  be  clear 
to  all,  it  would  soon  be  understood  that  the  higher  numbers 
meant  the  richer  milk.  If  this  practice  were  observed,  it 
would  be  difficult  for  drivers  to  tell  their  customers  one  thing 
and  the  milk  inspector  another  about  the  quality  of  the  con- 
tents of  the  same  can.  The  signs  should  be  so  attached  to  the 
wagon-side  or  can  that  they  could  not  easily  be  changed.  If 
bottles  are  used,  the  number  representing  the  quality  should 
be  attached  to  each  one. 

268 


CHAPTER    X. 

Origin  of  Alcohol,  Whiskey,  Brandy,  Port  Wine,  Sherry,  Champagne, 
Burgundy,  Claret,  Rhine  Wine,  Porter,  Ale,  Beer — Per  Cent,  of  Alco- 
hol in  Each — Effect  of  Alcohol  on  the  System — Effect  of  Alcohol  on 
Bodily  Temperature — Alcohol  as  Food — System  consumes  more  in 
Disease  than  in  Health — Strength  of  Wines — Colors  of  Wines — Na- 
tional Drinks — Methods  of  artificially  aging  Whiskey,  etc. — Rum,  Gin, 
Cordials,  Malt  Liquors — Method  of  making,  etc. — Malt  Extracts — 
Wines — Grapes,  Varieties  of,  etc. — The  Wine-Taster — Peculiarities  of 
Wines — Sherry,  Madeira,  Port — Ward  McAllister — Burgundy,  Sau- 
ternes,  Hock,  Johannisberg — Champagne  "  a  Drink  for  the  Gods."  as 
well  as  an  Invention  of  the  Devil — Vin  Brut,  Vin  Sec,  Vin  Tres  Sec, 
Sparkling  Moselle — German  and  Italian  Wines — American  Wines — 
California  Wines — Care  in  prescribing  Alcoholics — Value  of  Fruit 
and  Nuts  as  Articles  of  Diet  —  Value  of  Fruit  as  Food  from 
an  Economic  Stand-Point  —  The  Lesion  in  Rheumatism  —  Is 
Fruit  Healthy  Diet  ?  —  The  Divisions  of  Fruits  —  Special  Fruit 
Cures  —  The  Ripening  of  Fruit  —  The  Most  Digestible  Fruits 
— Fruit  Syrups  and  Fruit  Juices — Canned  or  Tinned  Fruits  and  Vege- 
tables— Fruits  in  Colonial  Times — Fruit  in  Florida,  California,  and 
Australia — Medicinal  Properties  of  Fruits  and  Nuts — Why  Leaves 
change  Color — The  Apple — Varieties  of  Apples — Varieties  of  Peaches 
— Varieties  of  Pears — Grapes — Apricots — The  Plum — East  India  Fruits 
— The  Mangosteen — The  Durian,  Pine-Apple,  Banana.  Plantain,  Or- 
ange, Shaddock,  Olives,  Lemons,  Mulberry,  Melons — Partridge-Berry 
and  Salicylic  Acid — The  Haw-Berry — Gooseberries,  Currants,  Cran- 
berries, Cherries,  the  Quince,  Blackberries,  Raspberries,  Strawberries — 
Decay  of  Fruit — Mushrooms,  Morels,  and  Truffles — Nuts — Chestnuts, 
Peanuts,  Almonds,  Filberts,  Pecans,  Shellbark  or  Shagbark.  Brazil 
Nuts,  Chilean  Nuts,  Betel  Nut,  Pistachio  Nut,  Kola  Nut.  Guarana. 
Butternut,  Walnuts — Eucalj-^ptus  Globulus. 

It  is  not  to  my  purpose  here  to  speak  particularly  of  alcohol. 
Absolute  alcohol  is  used  only  for  chemical  purposes,  as  a  rule. 
The  Pharmacopoeia  recognizes  alcohol  containing  ninety-four 
per  cent,  by  volume  of  absolute  alcohol,  and  having  the  spe- 
cific gravity  of  0.820.  Deodorized  alcohol  contains  95.1  per 
cent,  alcohol  by  volume,  with  a  specific  gravity  of  0.816. 
Dilute  alcohol  U.S. P.,  contains  48.6  per  cent,  by  volume  of 
absolute  alcohol,  with  a  specific  gravity  of  0.936.     Alcohol 

269 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

comes  from  sugar  by  fermentation,  as  is  well  known,  or  from 
the  destructive  distillation  of  organic  bodies.  Chemically  it 
is  an  ethyl  hydrate.  CoH-O.H. 

Whiskey  is  distilled  from  fermented  grains,  and  brandy  is 
distilled  from  fermented  grape-juices,  and  each  undiluted 
should  hold  from  forty-eight  to  fifty-six  per  cent,  of  absolute 
alcohol.  As  sold  in  the  markets,  whiskey  and  brandy  carry 
from  thirty-five  to  forty-five  per  cent,  of  alcohol.  Port  wine 
carries  from  eighteen  to  twenty  per  cent,  alcohol ;  Madeira, 
about  the  same ;  sherry,  about  sixteen  per  cent. ;  champagne, 
ten  to  eleven  per  cent. ;  Burgundy,  ten  per  cent. ;  claret,  six 
to  eight  per  cent. ;  Rhine  wines  the  same ;  porter,  five  to  six 
per  cent.,  and  beers  and  ales,  from  three  to  six  per  cent. 

According  to  Wood,  alcohol  increases  the  frequency  of  the 
pulse  and  increases  blood-pressure.  It  is  a  cardiac  stimulant, 
and  in  overdoses  is  a  heart  depressant.  There  is  one  thing 
well  to  remember :  there  is  an  apparent  contradiction  in  the 
effect  of  alcohol  on  bodily  temperature.  When  a  man  takes 
just  sufficient  to  slightly  increase  his  heart  action,  there  is  a 
very  slight  rise  in  temperature.  After  a  full  dose  there  is  a 
slight  fall  of  temperature,  and  when  a  man  is  fully  intoxicated, 
his  temperature  may  fall  as  much  as  3°  F.  The  explanation 
here  is  simple :  the  full  dose  drives  the  blood  to  the  surface 
where  it  is  cooled,  and  the  temperature  of  the  whole  body 
falls.  It  then  follows,  actually,  that  a  man  may  take  a  drink 
to  w-arm  him  up,  and  may  take  a  drink  to  cool  him  off,  and 
science  supports  him  in  both. 

A  drink  of  spirits  makes  the  breathing  freer  and  fuller. 
An  overdose  weakens  respiration,  and  this  is  often  seen  in  the 
case  of  drunken  men,  exclaiming  they  cannot  breathe  prop- 
erly. There  is  here  a  tendency  to  centric  respiratory  paralysis 
from  alcohol  poisoning.  I  have  always  been  taught  to  believe 
from  my  own  experience  that  alcohol  was  not  directly  a  food, 
but  that  a  man  could  live  longer  with  it  than  without  it,  be- 
cause he  did  not  die  so  rapidly ;  that  is  to  say,  with  a  certain 
amount  of  alcohol  daily,  destructive  change  of  his  tissues  did 
not  go  on  so  rapidly  as  when  that  certain  amount  of  alcohol 

270 


FORTY    YJCARS    IN    'I'll  I".    MICDICAL    PKOFJCSSION 

was  withheld  ;  but  the  recent  experiments  in  detail  by  Pro- 
lessor  Atwater  and  others  appear  to  give  to  alcohol  direct 
food  value,  but  this  is  not  yet  fully  settled. 

Horatio  Wood  sums  up  as  follows :  For  a  person  in  health, 
alcohol  must  be  considered  as  one  of  the  most  wasteful,  un- 
certain, and  often  deleterious  of  known  substances  which  are 
considered  foods.  In  disease,  however,  where  its  stimulating 
and  narcotic  purposes  favor  its  usefulness,  its  capability  of 
being  rapidly  burnt  up  without  undergoing  any  primary  as- 
similation, and  of  thus  yielding  force  to  an  exhausted  system, 
may  well  make  it  an  in\ahial)le  assistant  to  the  physician. 
The  human  system  will  burn  up  much  more  alcohol  in  disease 
than  when  in  health.  What  1  will  have  to  say  of  alcohol  will 
be  altogether  as  to  its  therapeutic  use  in  the  various  forms  of 
spirits,  wines,  and  malt  liquors.  These  in  moderate  amounts 
improve  digestion,  whilst  in  large  amounts  they  retard  or 
stop  it  altogether  for  the  time  being. 

Being  articles  of  the  materia  medica,  there  is  no  reason  why 
physicians  should  not  know  as  much  of  wines  and  liquors  as 
the}^  do  of  the  other  matters  therein  contained,  but  such  is 
apparently  not  the  case.  The  practitioner  should  at  least 
know  that  brandy  should  be  not  less  than  six  years  old  before 
it  is  fit  for  medicinal  use.  and  whiskey  should  be  five  years 
old.  He  should  know  that  port,  sherry,  Madeira,  and  cham- 
pagne are  the  stronger  wines,  and  that  the  Burgundies, 
clarets,  and  hocks  are  the  weaker.  He  should  know  that  the 
important  ingredients  of  wine  are  the  alcohol,  the  sugar,  the 
flavor  and  aroma,  and  the  relative  quantity  of  these  in  each 
kind.  He  should  know  the  relative  colors  at  least :  that  port 
has  usually  a  color  of  its  own.  the  port-wine  color,  approach- 
ing purple,  although  there  are  some  white  ports ;  that  sher- 
ries vary  in  color  from  very  pale  to  dark  red,  and  so  do  the 
Madeiras;  that  clarets  and  red  Burgundies  vary  in  red  or 
claret  colors,  and  that  Burgundies  are  many  of  them  white, 
but  true  clarets  never ;  that  the  hock  wines  are  usually  straw- 
color  or  white;  that  champagnes  vary  from  almost  white  to 
pink,  the  color  being,  as  a  rule,  at  the  fancy  of  the  maker : 

271 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

and  that  whiskeys,  brandies,  ales,  and  beers  vary  as  to  the 
demands  of  trade  for  this  or  that  color,  whiskey  and  brandy 
being  colorless  when  first  distilled,  but  are  colored  by  the 
addition  of  caramel  or  burnt  sugar.  Gin,  as  a  rule,  is  white, 
and  the  Irish  and  Scotch  whiskeys  are  either  colorless 
or  of  light  or  dark  straw-color.  The  cordials  are  usually 
colored  to  suit  the  fancy  of  the  manufacturers.  Whiskeys, 
brandies,  cordials,  and  all  artificially  colored  liquors  should 
be  left  as  nature  intended  them, — entirely  free  from  artificial 
coloring  or  artificial  flavoring.  Such  will  never  be ;  coloring 
for  the  eye,  flavoring  for  the  palate,  and  blending  for  both 
will  always  be  carried  on  so  long  as  "  water  shall  run  and 
grass  shall  grow."  It  is  said  that  the  Esquimo  has  no  alco- 
holic drink,  for  the  climate  is  too  cold  for  fermentation,  and 
he  cannot  make  it  there;  but  I  have  no  doubt  that  his  more 
southern  brothers  have  long  ere  this  supplied  him,  even  though 
alcohol  may  lessen  his  powers  to  resist  cold. 

Going  south,  we  find  all  nations  have  their  favorite  tipple, 
and  far  south  we  find  only  those  drinks  which  are  fermented 
in  a  hurry  and  drunk  in  a  hurry,  for  they  will  not  keep  over 
thirty-six  hours,  as  the  Mexican  pulque.  Brandy  is,  we  all 
know,  distilled  from  wines,  while  wines  are  fermented  grape- 
juice.  Brandy  in  the  market  is  of  various  colors,  owing  to 
the  amount  of  coloring-matter  put  in  it, — some  very  dark,  the 
pure  being  colorless.  The  best  brandy  I  ever  tasted  was  made 
in  California  and  sent  to  me  from  the  vaults  of  General  H. 
M.  Naglee.  It  was  selected  stock  from  the  time  the  grapes 
blossomed  until  it  was  barrelled  in  the  vaults.  It  had  no 
color  whatever,  no  artificial  flavoring,  but  had  the  rich  aroma 
of  the  grape,  and  no  headache  in  it.  This  is  the  kind  of 
spirits  we  should  dispense  for  our  sick,  but  we  cannot  always 
get  it.  To  make  brandy  we  must  add  color  and  the  true 
brandy  flavor,  in  addition  to  the  natural  ethers,  sold  in  any 
quantity,  to  give  it  the  hon  gout. 

Whiskey. — Probably  whiskey  is  the  safest  of  the  spirits  to 
use  in  the  United  States  for  the  sick,  as  it  at  least  ought  to  be 
the  purest,  and  it  should  be  the  cheapest.     Age  regulates  its 

272 


FORTY    YEARS    IN    TTTR    Mi'.DICAI.    PROFESSION 

price,  and  the  fusel-oils  in  it  decrease  by  aj^e,  so  old  whiskey 
is  the  best  and  safest,  provided  it  has  been  kept  in  vvrKKb 
There  are  artificial  ways  of  af:(in<;-  whiskey,  as  runninjj^  it 
down  a  woollen  string  from  the  higher  stories  of  a  building 
to  the  lower  stories,  each  running  down  evaporating  it  and 
losing  its  fusel-oils,  equivalent  to  one  year  passed  in  the  bar- 
rel. This  is  roguery  and  not  true  aging.  The  ])rice  of  whis- 
key, as  a  rule,  is  too  high  to  the  retail  purchaser,  but  the  trade 
controls  it  and  the  good  people  must  bear  it.  Rye  whiskey 
is  probably  the  best  in  this  country,  although  whiskey  is  made 
from  wheat,  barley,  corn,  and  other  grains.  The  flavor  comes 
from  the  process  of  kiln-drying  of  the  grain  or  grains  of 
which  it  is  made.  The  Scotch  and  Irish  whiskeys  get  their 
flavor  from  the  peat  used  in  drying  the  grains.  The  mashes 
used  in  making  whiskeys  are  the  sweet  and  the  sour,  and  corn 
and  rye  are  often  mixed  in  given  parts  with  malt.  This 
makes  sour  mash  if  scalded  with  the  refuse  liquor  used  be- 
fore, this  containing  the  ferment  to  start  the  alcoholic  fer- 
mentation. Sweet  mash  is  made  by  adding  water  only  and 
yeast  to  start  the  fermentation. 

Rum  comes  to  us  from  Jamaica,  Santa  Cruz,  and  New 
England  chiefly.  Molasses  is  fermented,  and  then  from  this 
the  rum  is  distilled.  Santa  Cruz,  with  the  lime  fruit,  makes 
the  best  punch,  but  it  does  not  compare  with  a  punch  made 
from  the  pure  California  brandy.  Let  me  digress  here.  We 
often  hear  the  doctor  say  he  is  giving  the  patient  milk  punch 
when  he  is  giving  him  whiskey  and  milk.  There  is  no  such 
thing  as  milk  punch  made  from  whiskey  and  milk.  Milk 
punch  is  made  from  brandy  and  milk.  Milk  toddy  is  made 
from  whiskey  and  milk. 

Gin  is  usually  colorless  and  has  some  diuretic  properties, 
owing  to  the  juniper  and  other  aromatics  in  it,  which  also 
give  it  its  peculiar  flavor.  Gin  is  distilled  from  almost  any 
fermented  grain,  but  the  grains  are  not  previously  kiln-dried. 
Then,  to  get  a  neutral  spirit,  there  is  a  second  distillation, 
and  to  this  the  flavoring  of  the  aromatics  is  added.  Gin  is 
a  strong  liquor.  The  English  call  it  Hollands,  and  Old  Tom 
1 8  273 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

gin,  a  favorite  brand,  is  sweeter  than  ordinary  gin.  Indi- 
vidually, I  do  not  cotton  to  gin,  and  I  do  not  advise  any  one 
else  to  cotton  to  it.  I  never  indulged  in  it  but  on  three  occa- 
sions, as  I  remember, — once  at  college,  when  it  made  me 
quite  ill;  the  next  time  when  I  took  a  cocktail  with  the  cap- 
tain of  a  clipper-ship  just  starting  on  a  long  voyage,  and  we 
were  shipwrecked  within  a  week ;  and  the  last  time  with  a 
friend,  on  the  birth  of  his  long-wished-for  son,  and  on  my 
next  visit  the  son  was  dead.  These  last  two  cocktails  were 
taken  before  breakfast,  that  heathenish  time  to  consume  spir- 
its, although  it  has  been  the  custom  of  my  lifelong  environ- 
ment. Thanks,  I  don't  take  gin,  even  though  Lord  Byron 
gave  it  renown  in  poetry  as  the  poor  man's  substitute  for 
riches ;  nor  do  I  drink  before  breakfast,  nor  before  noon,  and 
never  did  but  twice  in  my  life. 

There  are  other  spirits,  but  not  in  general  use,  and  it  is  not 
worth  while  to  take  space  to  enumerate  them.  Cordials  are 
not  often  of  use  to  the  sick,  but  if  needed,  the  best  are  char- 
treuse, hot  and  peppery,  and  probably  the  best.  Maraschino 
is  toothsome,  but  too  sweet.  Curagoa  is  of  orange-peel  flavor 
and  quite  useful  for  flavoring  unpleasant  medicines,  but  there 
should  be  no  use  for  it  now,  for  we  should  no  more  give  un- 
pleasant potions;  there  is  no  necessity  for  it.  There  are 
some  West  India  cordials,  as  parfait  I'amour  and  others,  but 
they  have  no  place  in  medicine.  As  to  cordials,  they  are 
merely  sweetened  and  artificially  flavored  spirits. 

Beer. — The  English,  as  a  rule,  speak  of  all  malt  liquors  as 
iDeer.  All  malt  liquors  are  fattening,  and  there  are  few  better 
mild  tonics  than  lager  beer,  and  given  in  connection  with  or- 
ganic iron  and  manganese,  you  have  a  combined  tonic  par 
excellence.  The  same  remarks  may  apply  to  all  malt  liquors 
and  malt  preparations.  Lager  beer  is  made  from  infused 
malt,  which  is  barley  dampened  and  allowed  to  germinate 
and  then  kiln-dried,  and  the  whole  flavored  with  hops.  The 
temperature  to  which  the  malt  is  brought  in  the  kiln  deter- 
mines the  color  of  the  product.  If  the  temperature  runs  below 
140°  F.,  you  get  pale  beer;   increasing  the  temperature  gives 

274 


FORTY    YEARS    TN    TIIP:    MRDICAL    I'ROFESSION 

you  (lark  hcer,  or  ale,  up  to  porter,  vvliicli  is  almost  hiack.  Of 
course,  by  the  maltinjj;'  process  the  starch  of  the  grain  is  con 
verted  into  dextrin,  and  so  on  up  to  sugar.  The  brewer,  tcj 
make  beer,  first  infuses  the  mah,  then  boils  it  with  hops,  which 
give  flavor  and  bitterness  and  keeping  (juality,  and  lastly  cools 
it  rapidly  and  adds  yeast  to  start  fermentation.  In  three  or 
four  days  the  fermentation  is  comi)leted,  the  alcohol  of  the 
beer  is  developed  (if  lager  beer,  about  three  per  cent.j,  and 
carbonic  acid  is  given  off.  The  product  is  then  allowed  to 
clarify  of  its  own  accord,  or  beech-wood  or  isinglass  is  used, 
which  carry  down  by  physical  laws  all  the  particles  which 
render  the  fluid  turbid.  Lager  beer  should  be  stored  in  dark, 
cool  vaults  for  from  four  to  eight  months,  or  even  longer,  to 
give  it  the  best  form.  As  now  produced,  it  is  said  to  be  put 
on  the  market  at  a  much  earlier  stage  of  its  life,  both  to  the 
detriment  of  the  beer  and  of  the  consumer.  Ale  is  made  from 
light-colored  malt  usually,  more  hops  are  used  to  give  it  a 
more  bitter  taste,  and  all  of  the  sugar  goes  to  alcohol,  giving 
it  an  average  of  six  per  cent,  alcohol.  Porter  is  strong,  dark 
ale  really,  the  malt  used  being  dried  at  a  greater  heat.  Brown 
stout  is  stronger  still,  both  porter  and  brown  stout  containing 
more  of  the  carbohydrates  extracted  from  the  grains  from 
which  they  are  made  than  either  ale  or  beer.  In  alcohol  they 
are  about  equal  to  ale.  Malt  liquors  fresh  from  the  wood  are 
better  and  more  healthy  than  the  same  products  bottled,  be- 
cause in  bottling  malt  liquors,  especially  for  exportation  from 
the  countries  in  which  they  are  made,  antiferments,  in  the 
shape  of  salicylic  or  boric  acid  and  such,  are  apt  to  have  been 
added,  all  of  which  slow  digestion.  For  the  same  reason 
many  of  them  are  reinforced,  and  thus  contain  more  than 
their  normal  proportion  of  alcohol.  So  it  will  be  seen  that  it 
is  usually  better,  provided  the  Boniface  keeps  his  pumps  and 
environment  clean,  to  "  rush  the  growler"  when  we  want 
pure  beer,  than  to  purchase  it  bottled. 

Now,  as  to  the  malt  extracts,  so  called,  of  which  the  shops 
are  full,  and  many  of  which  are  not  even  good  porter.  To 
make  true  malt  extract,  you  rapidly  evaporate  an  infusion  of 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

malt  to  the  consistency  of  thick  honey  at  a  temperature  not 
above  130°  F.  It  should  contain  all  of  the  diastase  in  the 
malt.  If  should  be  sweet  in  taste  and  of  acid  reaction,  and 
should  mix  easily  with  water.  Some  of  these  malts  are  really 
only  glucose,  and  some,  as  stated  above,  not  more  than  beers. 
To  be  right  it  should  not  contain  the  least  alcohol.  If  it  does, 
the  fermentation  has  gone  too  far.  If  it  contains  glucose  or 
alcohol,  it  is  a  food.  It  is  of  no  good  unless  it  contains  only 
diastase,  as  far  as  aiding  digestion  is  concerned;  that  is  to 
say,  its  claimed  merits  depend  on  diastase  and  not  on  glucose, 
alcohol,  and  such.  Acids  of  the  stomach  destroy  the  diastase, 
and  therefore  it  must  be  taken  before  meals,  before  the  stimu- 
lus of  the  food  draws  out  the  gastric  juices.  Of  whatever 
use  it  is,  it  is  to  aid  in  digestion  of  starches,  and  it  can  only 
do  this  when  it  meets  with  alkaline  or  neutral  surroundings, 
and  this  is  not  often,  for  starchy  indigestion  always  brings 
its  acidity.  As  a  rule,  then,  the  malt  extracts  of  the  shops  are 
trash,  and  worse  than  trash.  Have  your  patients  spend  their 
money  for  good  beer,  ale,  or  porter,  and  get  some  return 
for  it. 

Wines. — The  grape  is  renowned  in  song  and  story ;  in  his- 
tory, both  sacred  and  profane,  it  holds  a  leading  part,  and 
Bacchus,  its  mythological  god,  is  the  father  of  all  the  ills  it 
has  brought  to  the  world  and  the  hero  of  all  who  worship  at 
his  shrine.  What  a  power  for  good  and  what  a  weapon  for 
evil  environ  its  luscious  juices !  Botanically,  it  is  of  the  genus 
vitis,  the  type  of  the  order  vitacese.  In  the  wild  state  the 
flowers  of  some  specimens  are  imperfect  but  very  fragrant, 
but  in  cultivated  specimens  they  are  always  perfect  and  have 
the  delightful  odor  of  the  mignonette. 

The  horticulturist  now  divides  grapes  into  the  European 
and  American  varieties.  The  European  varieties  will  not 
grow  in  open  air  in  America  east  of  the  Rocky  Mountains, 
and  they  have  been  so  long  cultivated  in  Europe  for  flavor 
and  size,  that  the  vine  has  become  delicate  and  the  prey  of 
insects  and  fungi,  and  to  rehabilitate  it,  it  has  become  neces- 
sary to  grow  the  European  varieties  on  true  American  stocks 


FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

to  restore  tlicm  to  vi^or.  This  same  fact  is  often  shown  in 
nature,  not  only  in  fruits  and  vegetables  and  such,  but  in  ani- 
mals as  well.  In  American  grapes  the  seeds  are  held  together 
by  the  pulp,  which  slips  from  the  skin  easily.  In  foreign 
grapes  the  seeds  are  easily  extracted  and  the  skin  adheres  to 
the  pulp,  and  all  are  eaten  together.  The  grape  is  subject  to 
many  enemies,  botli  in  this  country  and  in  Europe,  of  which 
I  know  practically  something,  for  I  have  a  vineyard  of  my 
own  which  has  often  demonstrated  to  me  the  truth  of  the 
saying,  "  There  is  many  a  slip  between  the  cup  and  the  lip." 
The  phylloxera — Phylloxera  vastatrix — is  the  great  Euro- 
pean enemy,  and  also  in  California,  whilst  in  the  East  the  rots 
fungi  and  anthracnose  are  the  serious  troubles.  You  camiot 
raise  grapes  now  without  spraying  with  copper  solutions  and 
arsenites.  and  what  effect  these  sprayings  are  going  to  have 
on  the  yeast  fungus  which  nature  develops  on  the  stems  of 
grapes  to  set  up  the  wine  fermentations  is  for  the  future  to 
decide.  If  we  are  to  get  these  ferments  from  yeast,  the  flavor 
of  the  product  must  suffer. 

Wine  is  the  fermented  juice  of  the  grape.  The  finer  wines 
are  probably  still  made  in  Europe,  where  the  experience  of 
ages  gives  them  every  advantage,  but  x\merica  is  now  pro- 
ducing the  ordinary  wines  of  good  flavor  and  purity,  and 
these  are  far  better,  and  within  the  reach  of  all  pecuniarily, 
than  the  doubtful  and  expensive  foreign  wines,  unless  you  can 
get  these  out  of  the  line  of  general  trade,  from  special  sources, 
and  at  enormous  prices,  as,  for  instance,  champagne  of  a  cer- 
tain year  and  certain  vintage  at  one  hundred  dollars  per  dozen, 
which  is  frequently  paid  by  those  having  the  taste  and  the 
means  with  which  to  gratify  it. 

Forty  years  ago  I  drank  clarets  and  the  other  lighter  wines 
in  California.  Invariably  they  had  an  earthy  taste,  as  though 
filtered  through  earth.  They  had  not  the  least  idea  then  what 
particular  soil  and  what  particular  location  gave  certain  fla- 
vors to  the  grape  and  thence  to  the  wine,  a  fact  which  they 
are  rapidly  learning  now.  To  illustrate  this  point.  I  once 
visited  the  celebrated  Schloss  Johannisberger.  less  than  fifty 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

acres  in  extent,  on  the  Rhine,  where  that  fragrant,  aromatic, 
and  much-sought-after  wine  is  made  from  the  grapes  grown 
on  the  hill,  and  is  equalled  by  no  other  wine  of  its  kind  except, 
perhaps,  a  fine  old  Tokay.  The  gentleman  with  me,  an  at- 
tache of  the  place,  showed  me  much  as  to  the  intricacies  of 
getting  true  Johannisberg.  They  knew  the  soil,  every  foot 
of  it.  He  showed  a  place  on  the  hill-side,  say  thirty  feet 
square.  In  this  square  were  arranged  a  number  of  small  plots, 
and  every  one  of  these  small  plots  produced  a  grape  which 
gave  a  wine  of  a  different  flavor.  The  best  gave  a  wine  worth 
its  weight  in  gold, — the  genuine  Schloss  Johannisberger, — 
and  only  a  Metternich,  or  the  friends  of  the  house  of  Metter- 
nich,  ever  tasted  it,  and  so  on  down,  until  the  poorest  quali- 
ties went  to  the  general  trade ;  but,  he  added,  "  No  one  ever 
gets  a  bottle  even  of  the  poorest  Johannisberger  from  the  gen- 
eral trade.    If  he  thinks  he  does,  he  has  been  defrauded." 

The  United  States  Pharmacopoeia  now  divides  all  wines 
into  two  classes,  the  white  and  the  red,  and  leaves  off  special 
names,  by  reason  of  our  native  wines  coming  more  into  promi- 
nence. The  light  wines  are  those  which  contain  the  smaller 
per  cent,  of  alcohol,  as  clarets  and  hocks,  and  do  not  keep 
after  they  have  been  exposed  to  the  air.  These  have  about 
eight  per  cent,  of  alcohol.  The  heavy,  or  fortified,  or  rein- 
forced, or  brandied  wines  are  another  division,  and  keep  in- 
definitely when  exposed  to  the  air.  Sherry  and  Madeira  are 
examples  of  these,  and  they  contain  from  seventeen  to  eighteen 
per  cent,  of  alcohol.  We  have  sweet  wines  and  dry  wines.  A 
sw^eet  wine  is  sweet,  and  a  dry  wine  has  very  little  sugar.  We 
speak  of  a  sweet  or  a  dry  sherry.  We  speak  of  champagne 
as  dry,  extra  dry,  as  sec,  or  tres  sec,  and  of  Vin  Brut,  a  wine 
fermented  absolutely  naturally,  without  artificial  interference ; 
no  sugar  is  added,  and  the  natural  sugar  of  the  grape  has 
nearly  all  gone  to  alcohol.  True  dryness  is  a  result  of  age, 
the  sugar  being  slowly  converted  into  alcohol,  but  the  wine 
man  is  full  of  tricks ;  in  fact,  wine  is  subject  to  trickery  from 
the  grape  to  the  consumer.  To  hurry  up  dryness,  an  artificial 
acetous  fermentation  is  started  and  the  sugar  is  nearly  all 

278 


FORTY    YEARS    IN    'I'lII':    MF:[)1CAI.    PROFKSSION 

consumed  by  this  in  a  comparatively  short  time,  say  six 
months,  whilst  liu'  natural  process  may  take  years.  Thus 
is  champagne  dry  because  it  is  sour  frcm  the  development  of 
vinegar,  and  is  not  dry  because  the  sugar  lias  been  naturally 
converted  into  alcohol  as  it  should  be  to  be  good  wine.  Take 
this  wine,  let  it  become  exhausted  by  losing  all  of  its  free  car- 
bonic acid,  and  it  will  still  tinn  litmus  blue  to  red,  showing 
its  acidity  is  not  altogether  due  to  the  carbon  dioxide. 

There  are  various  terms  applied  to  wines  by  the  connoisseur 
which  it  is  well  to  be  familiar  with.  There  is  the  aroma  or 
bouquet ;  there  is  the  body,  that  which  makes  us  feel  as  though 
we  were  swallowing  something  better  than  water,  and  the 
nearer  wine  approaches,  in  swallowing  it,  to  water,  the  less 
bod}^  it  has.  Then  wine  has  color,  fruitiness,  astringency; 
strength,  due  to  its  alcohol ;  its  acidity  and  its  sparkle,  due  to 
its  carbon  dioxide  mainly.  If  it  were  not  for  the  sparkle, 
there  would  be  much  less  consumption  of  many  palatable 
drinks  than  there  is  at  present.  What  would  beer  be  wdthout 
its  sparkle,  or  champagne?  Try  exhausted  beer  or  exhausted 
champagne,  and  you  will  see. 

Wine  properly  used  has  a  good  efifect  on  the  system.  Its 
abuse  entails  untold  evils.  Liebig  said,  "  Wine  is  unsurpassed 
by  any  product,  natural  or  artificial,  as  a  restorer  of  the 
vital  forces  when  they  have  been  exhausted ;  it  animates  and 
revives  the  saddened  spirits,  it  serves  as  a  corrective  and  anti- 
dote in  all  irregularities  of  the  animal  economy,  which  it  pre- 
serves from  the  passing  ills  to  which  inorganic  nature  sub- 
jects it."  In  wine  there  is  a  union  of  alcohol  with  an  acid 
liquid ;  the  acid  holds  the  alcohol  in  check,  especially  the 
effect  of  the  alcohol  on  the  nerves:  the  tannin  and  coloring 
matters  favor  rather  than  retard  digestion,  and  the  bouquet 
serves  to  soothe  and  quiet  restlessness.  Wine  has  a  density 
nearly  equal  to  water ;  it  is  absorbed  much  less  rapidly  than 
spirits,  and  thus  its  effects  come  less  rapidly  and  last  longer 
than  the  effects  of  spirits.  Hence,  as  remedies,  when  you 
want  rapid  action,  use  spirits,  not  wine.  Wine  enters  the 
system  with  no  change  except  being  mixed  with  the  digestive 

2/9 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

jiiices,  and  absorbs  none  of  the  digestive  ferments  in  its  own 
digestion,  and  hence  its  nsefuhiess  in  dyspeptic  troubles. 

The  expert  wine-taster  is  an  important  man,  and  few  can 
individually  be  of  more  use  in  the  world.  Their  powers  of 
discrimination  by  taste  and  smell  are  beyond  belief,  and  such 
men  are  absolutely  necessary  to  protect  both  dealer  and  con- 
sumer, for  chemistry  has  become  such  a  science  as  to  make 
possible  the  imitation  of  all  beverages  without  the  presence 
of  any  of  their  natural  constituents.  It  is  responsible  for 
nearly  all  of  the  frauds  which  deceive  both  the  eye  and  the 
palate  and  overturn  the  digestive  processes.  The  wine-taster 
is  the  bulwark  here  which  separates  honesty  from  fraud.  Red 
and  white  wines  differ  materially  in  their  composition  and 
effect  upon  the  system,  and  it  is  important  for  physicians  to 
know  this,  and  it  is  growing  more  important  from  year  to 
year,  for  America  is  becoming  more  and  more  a  wine-pro- 
ducing country,  and  it  follows  that  we  are  becoming  more  and 
more  a  wine-drinking  people,  and  less  a  spirit-drinking  people. 
Statistics  show  this  undoubtedly. 

As  a  rule,  red  wine  is  fermented  in  contact  with  the  stems, 
seeds,  and  skins  of  the  grapes,  and  the  white  wines  are  fer- 
mented separately  from  these.  Guyot  says  the  difference  in 
color  is  an  accident.  The  real  difference  consists  in  the  spe- 
cial and  often  opposite  hygienic  qualities  of  these  two  kinds 
of  wine.  If  white  wine  is  fermented  from  white  grapes  in 
conjunction  with  their  seeds,  stems,  and  skins,  we  may  get  a 
white  wine  having  the  hygienic  qualities  of  red  wine,  not 
otherwise.  White  wines  made  without  using  the  stems, 
seeds,  or  skins  of  the  grapes  are  diffusible  stimulants  to  the 
nervous  system.  If  they  are  light,  they  act  rapidly  on  the 
physical  organization,  of  which  they  intensify  all  the  func- 
tions ;  they  escape  rapidly  through  the  skin  and  mucous  mem- 
branes, and  above  all  through  the  kidneys.  Red  wines  are 
more  tonic  and  persistent  stimulants  of  the  nerves,  the 
muscles,  and  digestive  organs ;  their  organic  action  is  slower 
and  longer,  they  are  not  eliminated  so  rapidly  from  the  sys- 

280 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

tern,  and  their  g'encral   action   is  astrinj:(cnt,   persistent,   and 
concentrated. 

Now,  here  are  the  well-defined  differences  between  red  and 
white  wines,  and  physicians  can  ])rofit  g-reatly  by  heeding 
them  in  prescribing.  Among  foreign  wines  we  will  first  take 
up  sherry,  which  is  a  Spanish  wine,  named  for  the  town  of 
Jerez  de  la  Frontera,  in  . Andalusia.  It  is  a  heavy  wine  and 
improves  by  age;  the  older  the  slierry  the  better  it  is,  pro- 
vided it  is  brut, — that  is  to  say,  if  nature,  not  art,  has  been 
allowed  to  work  it  out.  As  it  ages  it  gets  dryer,  because  the 
sugar  is  converted  into  alcohol,  and  if  old  enough  it  becomes 
inky  dry  for  the  same  reason.  Its  color  varies  from  dark  red 
to  almost  white.  By  the  makers  the  flavor,  which  is  a  pecu- 
liar ether  flavor,  the  sherry  flavor,  is  formed  by  the  soleras 
or  stock  wines.  This  stock  is  kept  up  and  used  to  flavor  wines 
in  bulk.  Solera  wine  is  no  more  palatable  than  sulphuric 
ether,  but  gives  the  flavor  to  all  sherries  as  it  is  added  in  larger 
or  smaller  quantities.  Sherries  are  all  reinforced  or  forti- 
fied by  brandy,  and  physicians  should  know  this.  The  Amon- 
tillado sherries  have  the  ether  flavor  most  strongly  marked. 
The  presence  of  aldehyde  causes  this  flavor.  The  Manza- 
nilla  sherries  are  so  named  from  their  flavor  resembling  the 
Manzanilla  or  chamomile  flower.  These  are  the  white  or 
nearly  white  sherries.  The  sherries  we  get  in  the  shops,  or 
from  dealers,  often  are  known  by  the  names  of  the  commer- 
cial houses  which  deal  in  them,  as  the  Gordon  sherries,  etc. 
Sherry  is  often  too  alcoholic  and  has  the  effect  of  spirits,  and 
it  is  not,  as  a  rule,  a  good  wine  for  the  sick,  except  used  as 
wine  whey,  and  I  do  not  recommend  this,  as  a  rule,  except 
when  we  are,  as  often  happens,  at  our  wits'  end  for  something 
palatable  to  the  patient.  There  is  one  place  it  comes  in,  and 
that  is  as  a  substitute  for  champagne  when  that  wine  is  too 
expensive  for  the  sick  one,  or  good  champagne  cannot  be  ob- 
tained. Mix  it  in  definite  proportions  with  the  common  soda- 
water  of  the  shops,  the  carbonic  acid  water,  made  by  charging 
water  with  carbon  dioxide  up  to  fifteen  atmospheres  at  least. 

28 1 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

and  served  to  customers  in  glass  siphons  which  preserve  it 
well  charged  until  all  of  the  contents  have  been  used.  Such 
a  mixture  will  often  be  found  of  the  greatest  benefit,  and 
should  be  much  more  used  among  the  sick  than  it  is. 

Madeira,  so  far  as  medicine  is  concerned,  is  a  passed  wine, 
but  it  is,  as  Ward  McAllister  called  it,  the  king  of  wines.  A 
physician  should  be  a  connoisseur  in  wines,  or  at  least  know, 
of  all  men,  something  about  them  and  their  merits  and  their 
history  when  they  are  discussed,  as  they  often  are,  so  cheerily, 
at  a  pleasant  dinner.  In  times  past  I  have  tasted  some  of  the 
good  ones,  and  the  flavor  of  a  Butler  i6,  or  of  a  Thorndyke 
Sercial,  or  a  Charleston  Blandy  of  1828,  lingers  still  close  to 
my  palate,  and  I  wish  I  could  enjoy  them  still,  and  that  my 
throat  was  as  long  as  a  gun-barrel  and  I  could  taste  them  all 
the  way  down.  I  cannot  do  it,  even  if  I  could  find  such  in 
existence,  for  the  old  stocks  must  have  nearly  passed  away, 
and  the  long  lapse  of  the  Madeira  grapes  from  disease  has 
made  impossible  the  replenishing  of  the  old  stocks,  and  the 
new  wines  are  as  yet  unfit  to  drink,  and  if  they  were,  probably 
modern  methods  will  make  impossible  the  old  wines  of  the 
honest  old  days.  Madeira  is  the  most  gouty  of  wines,  and 
many  among  us  cannot  touch  it,  even  if  we  get  it,  and  it  is 
not,  as  the  French  would  say  in  regard  to  Madeira,  "  chacun 
a  son  gout,"  but  rather,  "  each  one  as  to  his  gout." 

Ward  McAllister  said  Madeira  was  a  national  wine,  and 
only  matured  well  in  our  Southern  States.  It  raises  man's 
vitality  and  leaves  no  headache.  McAllister  said  age  always 
improved  a  good  Madeira  but  never  a  poor  one.  There  are 
stock  Madeiras  in  this  country  to-day  over  one  hundred  years 
old,  but  if  always  in  glass,  I  do  not  see  how  they  have  im- 
proved much,  unless  they  have  been  recorked  every  seven 
years  and  allowed  access  to  air  for  a  time.  McAllister's  best 
way  of  keeping  Madeira  was  in  the  garret,  with  a  corn-cob 
for  a  stopper.  Light  and  air  do  not  injure  its  flavor.  He 
always  said  that  the  thin  pipe-stem  wine-glass  was  the  only 
glass  from  which  to  drink  Madeira. 

282 


FORTY    YEAKS    IN    THE.  MEDICAL    PROFESSION 

Tlic  old  stock  Madeiras  were,  most  of  them,  named  from 
the  ships  which  hrout^ht  them  over,  and  the  famous  ones  were 
the  Marsh  and  Henson  1809,  tlie  Coles,  the  Stuyvesant,  the 
Clark,  the  EHza.  In  Philadelphia  the  lUitler  16  was  famous. 
In  Boston,  the  Kirby,  the  Amory  1800  and  [811,  and  the 
Otis.  In  Baltimore,  the  Marshall,  the  Meredith  or  Great 
Unknown,  the  Holmes  Demijohn,  the  Mob,  the  Colt.  In 
Charleston,  the  Rutledge,  the  Hurricane,  the  Earth(|uake,  the 
Maid,  the  Tradd  Street.  In  Savannah,  the  i\ll-Saints  1791. 
the  Catharine  Banks,  the  Louisa  Cecilia  18 18,  the  Rapid 
1817,  and  the  Widow.  I  will  add  the  Blandys  as  among 
the  noted  and  better  stock  wines  of  their  day.  One  of  the 
Blandy  brothers  was  the  head  of  a  well-known  Delaware 
family,  some  of  whom  reside  here  now. 

Cheese  and  nuts  bring  out  the  flavor  of  sherry,  port,  and 
Madeira,  and  this  is  why  they  come  in  so  well  and  cause  a 
cheery  lingering  over  the  wine.  This  all  may  appear  to  be 
fudge  and  gossip  as  introduced  here,  but  I  assure  you  it  is 
history  and  worthy  of  being  preserved.  In  the  old  days  many 
of  the  gentlemen  imported  their  pipes  of  Madeira,  even  from 
the  days  of  the  early  settlements  on  the  James  River  in  colo- 
nial times,  where  the  old  planters  exchanged  their  grain  for 
supplies  for  their  families  and  plantations,  and  the  pipe  of 
Madeira  was  a  frequent  article  in  the  exchange.  Again, 
should  any  professional  friend  at  any  time  have  one  of  the 
old  boys  '*  with  a  toe"  for  his  patient,  and  on  one  of  his  visits 
find  him  suffering  and  cast  down  and  even  emphatic  in  his 
remarks  condemnatory  of  gout.  I  advise  him  to  give  the  old 
gentleman  these  lines  to  read,  not  whereby  to  do  penance, 
but  to  bring  to  his  mind  possibly  visions  of  the  good  old  days 
now  past  and  gone,  and  to  help  assure  him  and  to  reassure 
him  that  there  had  been  other  sufferers,  too.  who  had  passed 
through  it  all.  and  that  again,  even  to  him,  dark  as  the  pres- 
ent may  look,  Ic  bo)i  temps  z'icudra. 

Port  wane  is  a  very  gouty  wine,  in  which  fermentation  has 
been  arrested  by  adding  a  certain  amount  of  alcohol.     It  im- 

283 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

proves  greatly  by  age  and  in  the  bottle,  it  only  being  neces- 
sary to  watch  the  corks  and  recork  it  about,  as  a  rule,  every 
five  or  six  years.  It  is  an  astringent  wine,  and  is  used  in 
diarrhoeas  when  wine  is  indicated.  It  is  often  used  for 
making  the  famous  "'  mulled  wine,"  which  is  a  good  tonic 
taken  with  a  cracker.  The  sweet  wines  are  of  little  use  in 
medicine ;  in  fact,  should  rarely  be  ordered.  The  Tokays, 
Malagas,  lachrymse  Christi,  etc.,  contain  more  sugar  and  less 
alcohol.  Age  renders  them  dryer  as  the  sugar  goes  to  alcohol, 
but  even  this  does  not  recommend  them,  even  for  sick  women, 
who.  as  a  rule,  defy  all  the  rules  of  hygiene  in  their  love  of 
sweets,  especially  the  cordials,  Malagas,  and  sweet  cham- 
pagnes. There  is  one  thing  to  remember  about  all  wines :  a 
sound  wine  may  be  acid,  but  this  acidity  is  owing  to  the 
natural  acid  of  the  wine,  tartaric  acid.  A  spoiled  wine,  or 
turned  wine,  is  sour  because  it  contains  acetic  acid  or  vinegar, 
which  has  developed  because  the  fermentation  has  gone  too 
far,  and  it  has  soured  just  as  cider  or  perry  sours  after  a  short 
keeping. 

What  is  the  difference  between  a  claret  and  a  Burgundy? 
Clarets  are  not  known  in  France  as  clarets,  but  are  known 
as  Bordeaux  wines,  and  common  wine  is  vin  ordinaire, 
which  may  apply  to  any  of  the  cheap  every-day  wines. 
The  Burgundies  are  stronger  wines  than  the  Bordeaux  or 
clarets,  and  are  therefore  more  gouty,  and  are  both  red  and 
white,  but  the  true  and  best  Burgundies  are  red.  True  Bur- 
gundy, as  the  French  understand  it,  is  made  from  the  grapes 
raised  in  the  department  of  Burgundy  called  Cote  d'Or,  the 
golden  side,  which  is  only  thirty-six  miles  long  and  reaches 
from  Chalon-sur-Saone  to  Dijon.  Chambertin  we  rarely  see 
in  America,  or  Corton,  or  Clos  de  Vougeot,  or  others  of  the 
true  Burgundies.  Burgundies  do  not  travel  as  well  nor  keep 
as  well  as  the  clarets,  and  hence  clarets  are  much  more  fre- 
quently seen  here.  The  best  white  Burgundy  of  the  Cote 
d'Or  is  the  Montrachet.  The  most  common  of  the  white 
Burgundies  we  see  in  America  are  the  Chablis  wines.     They 

284 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

are  good,  have  good  flavor,  and  are  desirable  for  the  sjck 
where  a  Burgundy  is  needed,  yet  they  are  not  absohitely  true 
Burgundies,  are  not  wines  made  from  the  Cote  d'Or  grapes. 

The  Bordeaux  or  claret  wines  are  named  Bordeaux  from 
the  city  of  Bordeaux,  the  capital  of  the  department  of  Gironde, 
France.  The  city  of  Bordeaux  is  the  centre  of  this  wine  trade. 
The  vineyard  name  of  the  district  is  the  Bordelais.  The  name 
claret  is  taken  from  the  French  clairet,  which  means  a  clari- 
fied wine,  and,  as  before  mentioned,  is  not  used  in  France  as 
a  name  for  wine.  The  Bordeaux  wines  are  mild,  not  very 
astringent,  pure  and  fragrant,  provided  you  get  fairly  good 
ones.  There  are  among  them  high-class  wines,  fine  wines, 
and  ordinary  wines.  As  a  rule,  a  sea  voyage  improves  them, 
whilst  it  deteriorates  Burgundies.  The  high-grade  clarets 
should  always  be  warmed  to  the  temperature  of  the  room,  in 
order  to  bring  out  their  bouquet  and  flavor.  They  gain  in 
bouquet  by  keeping  in  bottle,  if  properly  corked.  The  Medoc 
wines,  named  from  a  province  of  the  Bordeaux  country,  are 
among  the  best  of  clarets.  The  Chateau  Margaux,  the  Cha- 
teau Laffitte,  and  the  Chateau  Latour  are  rarely  seen  here  in 
their  true  form,  but  good  Medoc  wines  may  be  found.  Medoc 
wines  are  natural  wines,  are  not  reinforced  w^nes,  and  are 
therefore  mild  clarets.  We  do  not  know  now  what  we  get 
when  we  buy  foreign  clarets,  as  there  is  so  much  roguery  at 
Bordeaux,  and  the  remedy  is  to  use  those  made  in  our  own 
country,  unless  we  get  the  better  French  wines  from  some 
favored  source.  Among  the  best  of  the  red  wines  of  Bor- 
deaux is  the  Haut  Brion. 

The  Sauternes  are  white  and  are  sweeter  than  the  clarets, 
but  have  good  flavor  and  pure  aroma.  The  poor  grades  are 
sour.  Barsac  is  among  the  best  of  them,  if  Barsac  is  a  Sau- 
terne.  A  bottle  of  the  renowned  and  famous  Chateau  Yquem 
would  be  a  curiosity  in  America,  or  would  have  been  some 
time  since.  The  great  fortunes  accumulated  in  this  country 
can  now  buy  the  best  of  the  world's  luxuries,  and  the  high- 
priced  luxuries  will  follow  the  accumulated  money.     Chateau 

28s 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

la  Tour  Blanche  is  another  famous  brand.  The  best  of  the 
sweet  wines  are  the  Muscatelles,  Malvoisie.  and  the  Macca- 
beo.  They  are  sweet,  full  of  aroma,  and  full  of  vim.  They 
go  principally  to  Russia,  where  they  doubtless  turn  to  vinegar 
in  the  stomachs  of  the  unfortunate  subjects  of  the  great  Czar. 

The  Rhine  or  German  wines  are  usually  of  the  lighter 
character,  both  white  and  red,  but  the  white  far  predominate. 
They  are  low  in  alcohol,  but  yet  keep  well,  as  a  rule.  They 
have  much  free  acid  and  tartar  salts,  and  are  considered  allow- 
able in  patients  who  are  afflicted  with  calcareous  troubles. 
Hock  wines  are  so  named  from  the  district  of  Hockheim, 
from  whence  they  come,  near  the  banks  of  the  Main.  Johan- 
nisberg  is  the  prince  of  the  Rhine  wines,  and  I  have  already 
spoken  of  it.  If  any  one  wishes  the  best,  let  him  get  Johan- 
nisberg.  The  Riesling  grape  is  one  of  the  great  Rhine  grapes, 
and  we  will  see  more  about  it  when  we  come  to  speak  of  the 
California  wines.  It  is  most  interesting  to  visit  the  Rhine 
region,  the  Rheingau,  and  to  ponder  and  study  the  surround- 
ings, where  the  work  of  ages  has  been  carried  on  with  the 
grape  as  the  chief  factor.  Steinberg  is  a  brand  next  in  flavor 
to  Johannisberg,  and  in  some  seasons  is  better.  That  is  really 
the  case  with  all  brands  of  wine.  The  grape  of  the  brand 
makes  good  wine  this  year  and  poor  wine  next  year.  Ask  a 
judge  of  wine  about  a  brand,  and  he  will  first  ask  you  to  tell 
him  the  year  of  the  vintag-e  of  the  particular  specimen.  That 
makes  a  mighty  difference.  Other  brands  of  Rhine  wines 
are  Rupertsberger,  Deidsheimer,  Diirkheimer,  Liebfrauen- 
tnilch,  the  Fenerberger,  Laubenheimer,  Bodenheimer,  Nier- 
steiner,  and  many  others. 

The  Moselle  wines  are  light  in  alcohol,  have  much  fra- 
grance and  an  aromatic  flavor,  resembling  elder-flower,  which 
is  said  to  be  artificial.  The  Moselle  wines  make  good  spark- 
ling wine.  Sparkling  Moselle  I  have  drunk  frequently  on 
the  Rhine,  but  rarely  see  it  here.  Some  German  hocks  are 
also  fermented  and  made  to  sparkle ;  in  fact,  a  sparkling  wine 
may  be  made  of  almost  any  still  wine  by  the  arts  of  the  wine- 

286 


FORTY    YEARS    IN    Tllli    MEDICAL    PROFESSION 

maker.  The  Italian  and  ilnn<j^arian  wines  do  not  come  to 
us  in  any  quantity  except  they  come  in  wines  hom  France, 
for  much  of  the  wine  of  Italy  and  Mun,t;ary  f^nas  to  France 
for  blending-  purposes.  The  wines  of  Italy  are  chiefly  red, 
at  least  those  from  Northern  Italy  are,  and  they  are,  as  a 
rule,  rough  and  badly  made,  the  skins,  stems,  and  seeds  being 
macerated  too  long.  Some  of  llic  i  lungarian  light  wines  are 
of  fine  flavor,  have  good  aroma  and  smooth  taste,  and  are 
growing  in  favor  in  the  United  States.  The  white  Italian 
wines  come  from  middle  and  southern  Italy,  and  Tuscany; 
as  a  rule,  they  are  also  rough  and  badly  made. 

Champagne. — Professor  S.  D.  Gross  always  spoke  of  cham- 
pagne as  a  "  drink  for  the  gods,"  and  it  was  his  custom,  when 
he  came  home  weary  and  tired  out  from  hard  work,  to  open 
a  pint  bottle  of  Mumm's  Extra  Dry,  and  sit  down  and  enjoy 
it.  Whilst  champagne  is  undoubtedly  a  "  drink  for  the  gods," 
for  the  gouty  individual  or  for  the  diabetic  it  is  an  invention 
of  the  devil.  For  the  delicate  or  for  the  weary  valetudinarian 
it  is  a  generous  and  acceptable  tonic,  and  as  old  age  comes 
over  us,  provided  there  is  no  contraindication,  it  is  here  that 
alcohol  in  some  form  is  so  acceptable,  and  champagne  be- 
comes a  remedy  par  excellence.  Owing  to  the  carbonic  acid 
it  contains,  it  is  a  rapid  stimulant,  and  is  rapidly  and  com- 
pletely absorbed,  and  this  quality  makes  it  of  great  use  in  so 
many  of  the  acute  diseases  wdiere  we  need  rapid  action  and 
where  the  digestive  processes  need  just  the  spurring  up  that 
the  carbonic  acid  and  alcohol  give.  In  acute  croupous  pneu- 
monia confine  me  to  one  remedy,  and  I  believe  I  \\ould  choose 
champagne. 

There  are  true  champagnes.  "  Vin  Brut,"  as  the  French 
call  it,  \vine  made  without  any  artificial  additions  what- 
ever, and  fermented  absolutely  in  the  bottle.  Then  there  are 
the  ordinary  champagnes,  when  the  maker  hurries  up  the 
acetous  fermentation,  by  which  all  of  the  sugar  is  quickly 
converted  into  alcohol.  This  is  done  by  adding  from  four 
to  eight  per  cent,  of  sugar.     Four  per  cent,  makes  the  wine 

287 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

sooner,  and  it  is  ready  to  sell  sooner,  but  if  it  be  a  dry  wine 
it  is  dry  because  of  the  acetic  acid  in  it,  and  not  because  the 
sugar  has  gone  to  alcohol  naturally.  Here,  then,  is  the  distinc- 
tion between  "  Vin  Brut"  and  a  sec  or  dry  wine,  or  extra  dry. 
We  get  probably  little  *'  Vin  Brut"  in  the  United  States,  but 
we  get  plenty  of  dry  and  extra  dry.  Good  sec  (dry)  or  extra 
dry  (tres  sec)  can  be  bought  for  from  twenty-five  to  thirty- 
six  dollars  per  dozen  in  this  country,  whilst  true  Brut,  if  of  a 
fashionable  vintage,  will  sell  for  one  hundred  dollars  per 
dozen,  or  more,  and  is  usually  imported  by  the  consumer.  The 
only  wine  I  know  of,  sold  by  the  general  trade  in  this  country 
as  "  Vin  Brut,"  is  the  wine  of  Ruinart  Pere  et  Fils,  Rheims, 
France.  Roosevelt  &  Schuyler  are  sole  agents  for  the  United 
States  and  Canada.  It  is  a  good,  sound,  decidedly  dry  wine, 
but  I  do  not  see  how  it  can  be  a  true  Brut  wine  at  the  price, 
although  it  is  a  high-priced  wine  as  champagne  is  sold  in  the 
United  States.  I  am  in  error  as  to  Ruinart  being  the  only 
reported  Brut  wine  sold  here.  Moet  et  Chandon,  one  of  the 
very  best  French  makers,  offer  a  Brut  wine  as  Brut  Imperial, 
together  with  their  White  Seal.  Their  green  seal  pink  wine 
has  always  been  one  of  their  best.  Piper-Heidsieck  also  of¥er' 
a  Brut  extra.  The  genuine  Heidsieck  wines  are  among  the 
best,  but  this  brand  is  most  frequently  counterfeited  of  all 
wines,  probably,  coming  to  America.  Pommery  and  Greno, 
sec,  is  another  of  the  good  brands,  and  so  are  the  Veuve 
Cliquot,  but  these  are  usually  too  heavy  and  sweet  for  the 
sick.  The  wines  of  the  house  of  G.  IT.  Mumm  &  Co.  are 
among  the  best  and  most  reliable  of  champagnes  in  the  gen- 
eral market  in  this  country,  and  are  particularly  well  bottled 
and  corked,  and  this  is  of  great  importance  when  you  have 
wine  on  hand  any  length  of  time.  Mumm's  Extra  Dry  is  a 
very  fair  wine  and  safe  for  therapeutic  use. 

After  these  wines  come  champagnes  of  many  kinds  and 
sorts,  until  you  reach  the  vile  stuff  with  sugar  and  any  alco- 
holic mixture  for  a  base,  with  carbon  dioxide  forced  into  it 
soda-water  style.     I  will  not  speak  of  our  domestic  cham- 

288 


FORTY    YEARS    FN    THE    MEDICAL    PROFESSION 

pagnes  until  I  come  to  speak  of  our  domestic  wines  in  gen- 
eral. Artificial  champagnes,  as  a  rule,  besides  being  vile 
mixtures,  are  heady;  that  is  to  say,  the  carbonic  acid  goes 
rapidly  to  the  head  and  produces  an  unpleasant  fulness,  differ- 
ent from  that  produced  by  alcohol.  God  help  the  man  who 
drinks  too  much  at  one  time  of  the  best  champagne !  It  is  a 
sickening  dose,  but  if  the  stuff  is  artificial,  do  not  mention  the 
great  misery  which  overcomes  him.  Sparkling  Moselle  is  a 
fairly  good  light  wine,  and  if  it  can  be  obtained  it  can  be 
recommended  for  the  sick  when  such  a  wine  is  needed. 

The  making  of  good  champagne  is  a  tedious  and  expen- 
sive process,  and  consists  of  vatting,  curing,  bottling,  racking, 
disgorging,  and  handling.  The  bottles  must  be  of  the  best, 
and  even  then  fifteen  per  cent,  are  broken  in  the  process.  I 
remember  having  seen  men  testing  bottles  by  the  eye  and 
by  the  hands,  in  the  famous  cellars  of  Moet  et  Chandon,  £per- 
nay,  France.  The  only  wonder  to  me  was,  they  did  not  all 
fly  to  pieces  in  the  mere  testing.  The  slightest  bubble  in  the 
glass  condemned  the  bottle.  All  champagne  bottles  are  made 
in  clay  moulds,  and  have  no  mould-marks  on  them.  These 
bottles  must  stand  a  pressure  of  one  hundred  pounds  to  the 
square  inch,  thus  reaching  near  the  point  of  an  explosive, 
although  not  a  high  one.  This  is  in  the  first  fermentation. 
The  bottles  must  really  stand  a  pressure  of  twenty  atmos- 
pheres, or  three  hundred  pounds  to  the  square  inch.  Cham- 
pagne is  a  blended  w^ine.  The  cuvee,  literally  a  vat,  is  the 
mixture  or  blend  of  the  wine  from  which  the  champagne  is  to 
be  made.  The  cuvee  is  the  most  important  part  of  the  work 
of  making  champagne,  and  requires  great  experience  and  tact. 
It  is  necessary  to  ascertain  the  exact  proportion  of  alcohol, 
sugar,  and  acid,  or  the  mousse  or  sparkle  will  be  too  violent, 
or  not  violent  enough.  The  blend  of  the  wine  gives  the  color, 
lightness,  its  sweetness  or  dryness,  and  the  strength,  in  a 
great  measure. 

Now  the  corking  is  done  by  machinery,  and  it  is  an  inter- 
esting process.  Formerly,  string  and  wire  both  were  used 
19  289 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

to  hold  the  corks ;  now  much  wine  is  tied  by  wire  alone. 
After  the  bottles  have  been  filled,  they  are  tied  with  one  string, 
and  are  then  kept  at  a  temperature  of  about  80°  F.  for  several 
months.  During  this  time  the  albumin  and  natural  sediment 
of  the  wine  goes  to  the  lower  side,  the  bottles  having  been 
kept  on  their  sides.  At  the  end  of  several  months  the  carbon 
dioxide  has  formed,  and  probably  ten  per  cent,  of  the  bottles 
have  exploded,  yet  the  wine  is  not  always  lost,  but  is  caught 
in  gutters  and  used  sooner  or  later. 

After  fermentation  has  gone  on  for  months  the  bottles  are 
put  into  racks  and  turned  every  day  for  several  months.  This 
brings  the  sediment  down  to  the  neck,  the  racks  holding  the 
bottles  cork  down.  After  this,  the  bottles  are  stood  up  per- 
pendicularly on  their  corks.  All  champagne  bottles  have  their 
bottoms  pushed  up  into  a  cone,  as  is  well  known.  This  is  not, 
as  is  generally  supposed,  to  reduce  the  contents  in  quantity, 
but  is  necessary  for  the  strength  of  the  bottle.  After  fermen- 
tation has  been  completed  the  sediment  must  be  gotten  rid 
of,  technically  called  disgorgement.  A  man  does  this  very 
expertly,  and  loses  very  little  of  the  wine.  He  wears  a  wire 
mask,  as  do  all  who  enter  the  champagne  vaults  during  the 
cure  of  the  wine.  If  the  wine  is  to  be  helped,  and  is  not  abso- 
lutely natural,  or  brut,  as  soon  as  the  disgorger  has  finished, 
another  man  puts  in  the  proper  amount  of  syrup,  and  thus 
arranges  for  the  dryness  or  sweetness  of  the  wine.  The 
syrup  is  cold  process  syrup  only,  and  made  with  grape  sugar, 
and  may  have  some  flavoring  added,  but  this  is  really  not 
proper.  If  too  much  wine  has  been  lost  in  disgorging,  more 
is  added,  and  the  waste  goes  off  into  some  such  by-product 
as  vinegar.     Nothing  is  wasted. 

After  the  wine  has  been  corked  and  wired  it  is  put  away 
for  probably  a  year  in  the  cellars,  and  is  then  ready  for  label- 
ling and  packing.  I  think  there  is  a  difference  of  opinion  as 
to  the  improvement  or  non-improvement  of  champagne  by 
age.  If  it  can  be  kept  absolutely  quiet  and  air-tight,  and  with 
a  proper  environment,  it  may  improve  by  age,  certainly,  at 

290 


FORTY    YEARS    IN    TIIF.    MEDICAL    PROFESSION 

least,  until  all  of  the  sugar  has  been  converted  into  alcohol, 
the  wine  then  becoming"  as  dry  as  it  can  ever  be.  The  life  of 
the  cork  must  measure  the  life  of  the  wine,  and  this  is  prob- 
ably not  over  five  or  six  years  on  an  average. 

France  makes  most  of  the  champagne  for  the  world,  and 
the  true  champagne  district  cann(jt  supply  grapes  sufficient 
for  one-tenth,  probably,  of  what  France  exports.  Fortu- 
nately, there  are  other  places  which  furnish  grapes  for  good 
champagne,  and  this  wine  is  utilized.  Champagne  is  sup- 
posed to  have  been  invented  by  monks,  and  resulted  from 
the  bottling  of  new  wine  and  its  exploding  the  bottles  whilst 
undergoing  fermentation.  The  true  champagne  country  of 
France  is  the  department  of  the  Marne,  east  of  Paris,  and 
which  one  passes  through  in  going  from  Paris  to  Strasbourg, 
on  the  way  going  through  fipernay,  Rheims,  and  Nancy.  The 
German  army  went  by  this  route  on  their  way  to  Paris  after 
Sedan.  The  surface  soil  is  shallow,  the  subsoil  calcareous  and 
chalky.  The  subsoil  analysis  is,  carbonate  of  lime,  80;  car- 
bonate of  magnesia,  2;  silica,  18.  Surface  soil  analysis  :  alka- 
line salts,  .985;  carbonate  of  lime,  28.862;  magnesia,  1.401 ; 
oxide  of  iron,  4.545;  phosphoric  acid,  .147;  alumina,  .849; 
soluble  silica,  .095;  organic  matter,  3.750;  insoluble  resi- 
due, 59.366. 

Dealers  in  wine  will  tell  you  that  brands  of  wine,  especially 
of  champagne,  like  brands  of  cigars,  are  likely  to  deteriorate 
after  the  brand  has  been  well  established,  and  recommends 
the  newer  brands  as  often  the  best.  This  may  be  the  case, 
but  I  think  the  character  of  wines  is  most  frequently  deter- 
mined by  the  year  of  the  vintage,  as  the  grapes  differ  so  much 
in  different  years,  one  year  making  good  wine,  and  another 
year  making  very  inferior  wine. 

American  Wines. — Within  fifty  years  wine-making  has  be- 
come quite  an  industry  in  the  United  States,  and  to-day  Cali- 
fornia, Missouri,  New  Jersey.  Ohio,  and  Virginia  furnish  a 
great  deal  of  very  good  wine,  especially  of  wines  of  the  lighter 
kinds.     These  wines  are  doubtless  purer,  and  often  better. 

291 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

than  the  foreign  wines,  for  they  are  so  cheap  that  it  does  not 
pay  to  take  the  trouble  or  expense  either  to  change  them  or  to 
counterfeit  them.  In  1894  the  producer,  for  his  hghter  wines 
in  CaHfornia,  could  barely  command  six  cents  per  gallon  in 
his  vaults,  scarcely  the  price  of  good  cider  as  we  find  it  in  the 
general  market.  California  is  our  great  wine-producing  State. 
In  1898  she  exported  fifteen  millions  of  gallons  of  wine,  and 
there  the  business  is  in  its  infancy,  and  doubtless,  as  years  go 
by,  there  will  be  a  wonderful  development,  and  a  great  rival 
will  arise  to  France  and  Germany  and  all  of  the  other  great 
wine-producing  countries  of  the  world. 

It  is  the  duty  of  our  physicians  to  know  all  about  our  native 
wines  and  spirits,  for,  as  a  rule,  they  are  within  the  reach  of 
all  in  price,  and  equal  to  any  we  can  buy  in  efficiency,  and 
there  is  every  reason  why  we  should  use  them  therapeutically 
almost  exclusively.  When  we  ferment  the  grape  the  sugar 
of  the  grapes  is  transformed,  on  an  average,  into  alcohol, 
48.4  per  cent. ;  carbon  dioxide,  46.6  per  cent. ;  glycerin,  3.3 
per  cent.  The  malic  acid  is  converted  into  succinic  acid,  .5 
per  cent.,  and  the  yeast  ingredients  1.2  per  cent.,  making  in  all 
100  per  cent.  The  germs  come  from  the  atmosphere,  where 
they  exist  always  in  the  lower  strata.  On  tops  of  mountains, 
perhaps,  natural  fermentation  would  not  start  owing  to  the 
absence  of  yeast  germs,  but  here  we  could  start  it  by  adding 
old  must  or  yeast.  Natural  fermentation  is  best.  Here  is 
an  important  point:  if  the  fermentative  germs  do  not  exist 
on  mountain-tops,  it  is  reasonable  to  suppose  the  pathogenic 
germs  do  not  exist  there.  Indeed,  I  have  my  doubts  if  tu- 
bercle bacilli  flourish  at  an  elevation  of  over  five  thousand 
feet  above  sea-level.  The  same  may  be  the  case  on  the  high 
seas  and  in  deep  canons  and  such  places.  In  California  wines 
mature  much  more  rapidly  than  they  do  in  Europe.  In  the 
future,  we  may  expect  wines  from  the  Pacific  coast  of  a  high 
character,  especially  of  the  Medoc  type,  and  Burgundies,  true 
Sauternes,  and  those  of  the  cognac  type.  I  have  never  yet 
seen  a  real  good  sherry  among  them ;  there  is  too  much  sugar 

292 


FORTY    YEARS    TN    THE    MEDICAT.    PROFESSION 

in  tlieir  sherries,  and  the  same  may  be  said  of  those  oi  the 
Madeira  type.  Some  of  tlie  |K)rt  wines  are  fair,  and  arc  par- 
ticularly to  be  recommended  for  therapeutic  use.  California 
sherries  and  ports  are  usually  sold  in  the  shops,  not  by  any 
particular  name,  but  by  the  vintage,  which  really  means  noth- 
ing, as  choice  old  port  1885,  pure  port  1880,  extra  port  1870, 
and  so  on ;  and  the  same  with  the  slierrics  and  those  of  the 
Madeira  class. 

The  California  wine  business  has  fallen  into  the  hands 
of  trade  entirely,  and  the  wine,  after  it  leaves  the  cellars  of 
the  producers,  is  subject  to  all  the  arts  and  manipulations  of 
a  not  over-scrupulous  set  of  dealers,  and  those  who  drink  it 
must  take  the  best  they  can  get. 

This  is  really  the  case  with  all  wines,  even  down  to  spu- 
rious and  artificial  wines.  The  California  hocks,  Rhine  wines, 
and  Sauternes,  as  we  find  them  in  the  trade,  take  the  names  of 
the  true  hocks,  Rhine  wines,  and  Sauternes,  as  Haut  Sau- 
terne,  Choice  Old  Liebfrau  Milch,  Rudesheimer,  Hockheimer, 
and  such.  Of  these  wines,  I  like  the  true  California  Rieslings 
the  best.  The  sweet  wines  of  California  are  sold  as  Choice 
Old  Muscatel,  Choice  Angelica,  and  such,  and  are  among  the 
best  of  these  wines  obtainable,  if  they  come  from  a  good 
source.  California  Burgundy  we  find  in  our  markets  as  Bur- 
gundy 1885,  Burgundy  1880,  and  so  on.  The  clarets  come 
under  a  number  of  names.  The  Zinfandels,  to  my  mind,  are 
much  the  better.  The  Zinfandel  grape  has  a  peculiar  flavor 
of  its  own,  which  pervades  the  claret  and  grows  on  one  rap- 
idly. Of  course,  to  get  the  best  results  in  flavor,  etc.,  the 
wine  is  blended  with  the  red  and  white  Zinfandel  and  other 
wines,  Zinfandel  predominating  largely,  until  the  desired  re- 
sult is  obtained.  These  California  clarets  are  stronger  in 
every  way  than  the  foreign  clarets,  and  approach  near  to  the 
Burgundies,  and  need  water  added  to  them  when  used  as  or- 
dinary table  wine.  The  Cabernet  Sauvignon  makes  a  high- 
class  Bordeaux  wine  alone,  and  the  Burgundy  Pinot  grape 
does  the  same,  but  these  are  among  the  few  on  the  Pacific 

293 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

coast  that  do  not  need  blending.  We  find  in  the  shops  clarets 
under  the  names  of  Medoc,  Cabernet,  St.  Jnlien,  Larose,  Pon- 
tet  Canet,  Santa  jMonica,  and  others.  The  Zinfandel  grape 
has  been  very  extensively  planted  in  California;  it  is  hardy 
and  flourishes  everywhere,  and  for  this  reason,  among  others, 
it  is  the  greatest  claret  grape,  and  properly  blended,  as  Zin- 
fandels  we  get  the  best  of  the  California  clarets,  although  the 
Medoc  class  might  possibly  be  better  could  we  get  them  from 
first  hands.  The  Zinfandel  has  a  bouquet  of  its  own,  is  of 
light  astringency,  and  has  a  light  color. 

There  is  no  manner  of  doubt,  as  we  purchase  medium- 
priced  clarets  in  the  general  market,  that  the  California  and 
other  American  clarets  are  far  better  than  the  adulterated 
stuff  we  usually  get  from  abroad.  I  do  not  hesitate  to  advise 
their  use  generally.  Some  very  good  clarets  are  made  in  New 
Jersey  near  the  coast,  and  among  the  best  of  American  clarets 
I  have  ever  tasted  are  those  made  in  Virginia, — near  Char- 
lottesville, I  think.  Physicians  in  seeking  for  good  sound 
wines  of  this  class  should  not  overlook  these  Virginia  clarets. 
Should  we  need  a  sweet  wine,  the  Virginia  Scuppernongs 
are  worth  testing.  Of  the  hock  varieties  of  California,  I 
prefer  the  Rieslings.  The  Riesling  is  the  noble  grape  par  ex- 
cellence of  the  Rhine,  and  predominates  in  the  famous  Johan- 
nisberg  vineyard.  I  believe  a  true  Johannisberg  will  be  made 
in  California  much  better  than  we  can  buy  of  European  origin 
in  our  market,  if  you  can  buy  any  at  all.  If  you  wish  one  of 
the  best  wines  of  the  Rhine  wine  type  to-day,  buy  the  Califor- 
nia Riesling  in  preference  to  the  average  foreign  wine. 

This  brings  us  through  the  list  of  American  light  wines 
and  other  wines,  except  the  sparkling  wines, — champagne,  the 
true  "  Vin  de  luxe."  Let  me  add  here,  that  Calif ornians  ac- 
cuse the  dealers  who  buy  their  wines  of  shipping  them  in 
bulk  to  Europe  and  bringing  them  back  here  with  European 
high-sounding  labels  on  them,  and  selling  them  to  us  as  genu- 
ine European  wines.  The  way  for  us  to  stop  this  is  to  drink 
our  own  wines,  as  we  should  do,  whenever  possible.     As  to 

294 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSIOr: 

American  clicinii)agnc,  1  caniu^t  say  much  for  it.  After  look- 
ing into  the  matter  quite  thoroughly,  I  have  come  to  the  con- 
clusion that  tliere  is  very  little  true  chani])agne — that  is,  cham- 
pagne fermented  in  the  hottle — made  in  America.  We  have 
plenty  of  soda-water  champagne,  and  some  of  this  is  quite 
pleasant,  and  serves  a  good  part  in  taking  the  place  of  the 
more  expensive  European  wines.  It  is  easy  to  make  artificial 
champagne  from  the  natural  dry  wines.  An  Italian,  Carpene 
by  name,  has  invented  a  simple  and  cheap  apparatus.  The 
result  of  Carpene's  apparatus  is  a  fairly  good  sparkling  wine, 
at  a  very  moderate  cost. 

Old  Nicholas  Longworth,  of  Cincinnati,  years  ago  made  a 
sparkling  Catawba,  which  was  probably  fermented  in  the 
bottle.  Arpad  Haraszthy  some  years  ago  made  a  good  cham- 
pagne in  California,  which  he  called  the  "  Dry  Eclipse."  I 
believe  this  wine  was  fermented  in  the  bottle.  Haraszthy's 
"  Eclipse  Champagne"  is  yet  on  the  market,  but  I  think  he 
is  probably  dead  some  time  since.  It  is  yet  one  of  the  best 
of  our  domestic  sparkling  wines,  but  whether  it  is  bottle  fer- 
mented now  or  not  I  do  not  know.  "  Golden  Age"  is  one  of 
the  better  domestic  brands,  and  so  is  Urbana  and  the  Great 
Western  of  the  Pleasant  Valley  Wine  Company.  Cook's 
Imperial  Extra  Dry  is  a  fruity  wine,  and  pleasant.  As  a  rule, 
our  domestic  champagnes  lack  body  and  are  too  sweet.  They 
sell  by  the  case  at  from  twelve  to  fifteen  dollars  per  dozen  for 
quarts,  and  for  pints  they  cost  a  trifle  more.  No  good  reliable 
house  can  or  will  sell  a  domestic  champagne  fit  for  one  to 
drink  much  below  these  prices.  The  stufifs  in  the  market 
under  these  prices  are  slops,  and  w-orse  than  slops. 

American  brandies  are  chiefly  made  in  California.  They 
are,  as  a  rule,  cheaper  and  much  better  than  the  ordinary 
French  brandies.  If  some  one  in  the  business  in  California 
would  supply  physicians  and  their  patients  with  a  natural 
brandy, — a  brandy  distilled  from  good  pure  wine,  and  bottled 
without  adding  artificial  flavoring  or  any  coloring  matter 
whatever. — he  would  do  a  great  good  to  suffering  humanity, 

295 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

and  undoubtedly  be  rewarded  by  large  financial  returns.  The 
resultant  liquor  would  be  better  than  all  the  whiskeys,  rums, 
and  other  spirits  on  the  market  for  its  special  purposes. 

Unfermented  grape- juices  are  now  much  used  by  soda- 
water  men  and  temperance  people,  so  called.  Grape- juice, 
fresh,  may  be  very  nice  and  quite  palatable.  To  prepare  it, 
it  is  boiled  more  or  less,  and  bottled  and  sealed.  Much  of 
it,  to  keep  it,  has  some  antiferment  added,  and  this  is  done 
particularly  when  it  is  retailed  in  small  quantities ;  and  under 
these  conditions  it  is  unwholesome  and  adds  another  turn  to 
the  screws  that  Satan  will  give  the  soda-water  men  when  he 
gets  hold  of  them  for  all  the  vile  stuffs  they  have  cunningly 
devised  for  credulous  humanity. 

Adulterated  wines  and  spirits  of  various  flavors  are  used 
and  wholesale  adulteration  is  carried  on,  and  no  law  appears 
to  check  it.  You  can  buy  any  wine,  brandy,  or  whiskey  in  a 
general  market,  or  receipts  for  making  them,  and  no  genuine 
juice  of  the  grape  or  grains  will  in  any  way  enter  into  their 
composition.  Such  concoctions  are  called  "  rot-guts,"  but 
they  do  not  appear  to  kill  more  rapidly  than  the  better  and 
truer  stuffs.  Those  who  take  them  are  generally  the  poor 
among  the  dissipated,  who  have  not  the  means  to  overeat 
and  over-drink  which  those  have  who  are  more  prosperous 
financially.  The  drunkard  with  unlimited  means  often  goes 
sooner  and  more  rapidly  than  the  tramp  and  "  bum"  with  no 
means  whatever.  As  adulterants,  ginger  and  peppers  are 
used,  cocculus  indicus,  quassia,  aromatic  seeds,  wormwood, 
ammonia,  nux  vomica,  gentian,  juniper,  chamomile,  almonds, 
orange-peel,  licorice,  honey  and  other  sweets,  and  astringents. 
In  wines  there  is  great  roguery.  According  to  Thompson,  a 
fair  imitation  of  Chateau  Latour  can  be  made  with  almonds 
and  other  nuts,  and  a  Chateau  Lafitte  with  violets  and  nuts; 
and  to  other  grades  cherry- juice  is  added.  Artificial  pig- 
ments, alum,  tannin,  fusel-oils,  cider,  pear- juice,  and  lime  salts 
are  often  added  to  wines.  Logwood  is  frequently  added  to 
make  clarets  and  Burgundies.     It  is  the  fusel-oil  in  liquors 

296 


FORTY    YliAKS    IN    'JllIC    MEDICAL    PROFESSION 

that  usually  causes  headache,  ioul  mouth,  and  dyspeptic  symp- 
toms following  their  use;  and  if  carried  on  too  long  the  hob- 
nail liver  comes  with  all  its  succeeding  horrors.  There  is  no 
longer  taste  for  even  Chambertin  or  Chateau  Yquem. 

Wines  are  made  from  almost  any  fruit  or  vegetable  con- 
taining sugar, — as  fn »ni  rhul)arb,  the  tomato,  the  fig,  the 
strawberry,  the  blackberry,  the  raspljerry,  and  the  currant. 
That  made  from  the  latter  is  among  the  best.  If  such  an 
excess  of  sugar  were  not  usually  added,  these  wines  might 
be  useful  in  sickness.  As  usually  seen,  they  are  a  sorry  dose 
for  sick  or  well. 

Cider  and  perry — the  first  from  the  juice  of  the  apple,  and 
the  other  from  that  of  the  pear — are  common  drinks.  They 
contain  a  small  amount  of  alcohol,  malic  acid,  some  extrac- 
tives, sugar  when  new,  and  some  salts.  When  first  fermented 
they  are  very  palatable,  but  soon  get  sour  and  go  to  vinegar. 
Cider  in  France  is  used  as  a  gout  cure.  For  the  life  of  me,  I 
cannot  see  why  or  how  it  can  add  to  the  alkalinity  of  the 
blood,  except  by  forming  salts  in  the  system  with  the  bases  it 
meets,  and  even  then  not  enough  to  have  any  practical  effect. 
I  have  known  one  or  two  gentlemen  who  lived  in  France 
to  declare  it  did  them  great  good.  Those  of  our  patients  who 
need  cider  had  better  always  drink  fresh  cider.  All  bottled 
cider,  as  a  rule,  is  cider  in  which  fermentation  has  been  lim- 
ited by  the  addition  of  antiferments,  and  is  neither  palatable 
nor  proper  to  drink. 

It  is  wonderful  the  number  of  articles  made  from  the  wine 
residues,  and  many  of  them  are  of  every-day  therapeutic  use. 
Those  products  that  furnish  the  greater  number  of  articles 
are  the  pomace,  the  lees,  and  the  tartar.  Tartaric  acid  is  ob- 
tained from  the  pomace  by  a  complex  process.  Spirit  is  made 
from  the  pomace  by  distilling  it.  Frankfort  black  is  made 
from  the  pomace.  Oil  and  tannic  acid  are  extracted  from  the 
seeds,  and  vinegar  is  made  from  the  pomace;  but  true  wine 
vinegar — the  best  vinegar — is  made  from  true  wine  gone  on 
to  the  acetous  fermentation.     QEnocyanin.  a  coloring  matter, 

297 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

is  made  from  the  skins,  and  is  much  used  in  wine-making" 
for  coloring  purposes.  Verdigris  is  made  from  the  pomace 
and  copper.  Grape  pomace  is  also  used  for  food  for  stock 
and  for  fertilizing  purposes,  I  suppose  from  the  salts  of 
potash,  nitrogen,  and  phosphoric  acid  formed  in  it.  The  lees 
contains  alcohol  and  tartrates,  and  is  valuable  as  to  the  quan- 
tities of  these  contained.  The  common  raw  tartar,  or  argol, 
is  a  very  valuable  by-product  of  the  grape,  and  is  precipitated 
on  the  lower  side  of  the  barrels.  This  tartar  salt  is  usually  in 
composition  as  potash  or  lime  salt.  There  are  two  kinds  of 
raw  tartar,  the  white  and  the  red.  Raw  tartar  is  a  great  com- 
mercial product,  and  it  is  therefore,  like  many  other  articles, 
much  adulterated,  sand  being  used,  and  also  steam-boiler 
crusts.  Physicians  should  know  about  such  matters.  Tar- 
taric acid  is  made  from  the  raw  tartar  by  an  interesting 
process.  It  is  first  changed  to  calcium  tartrate,  then  by  sul- 
phuric acid  all  the  tartrate  of  lime  is  made  into  sulphate 
of  lime  and  tartaric  acid,  the  calcium  sulphate  precipitating. 
The  tartaric  acid  is  then  crystallized  out.  Tartar  emetic  is 
a  double  tartrate  of  potash  and  antimony.  The  acid  tartrate 
of  potash,  cream  of  tartar,  a  bitartrate,  is  a  very  important 
by-product  from  the  grape.  The  neutral  tartrate  of  potash 
is  also  a  well-known  substance.  There  is  another  salt,  a  very 
valuable  one,  and  one  deservedly  used  in  medicine,  the  double 
tartrate  of  soda  and  potash,  called  the  Rochelle  salt.  This 
has  a  mild,  not  unpleasant,  salty  taste,  and  we  all  should  know 
that  it  is  one  of  the  good  things  coming  from  the  grape  as  a 
by-product  in  the  art  of  wine-making. 

From  the  official  reports  of  the  British  Board  of  Trade 
we  can  compare  the  consumption  of  alcoholic  drinks  in  Eng- 
land, Germany,  France,  and  the  United  States.  In  France  the 
consumption  of  wine  increased  from  21.3  gallons  per  capita  in 
1885  to  29.5  gallons  per  capita  in  1896.  In  Germany  the 
consumption  of  wine  is  1.06  gallons  per  capita  per  year.  In 
England  it  is  four-tenths  of  a  gallon  per  capita  per  year,  and 
in  the  United  States  it  is  twenty-two-hundredths  of  a  gallon 
per  capita  per  year.     All  these  show  a  slight  increase  from 

298 


FORTY    YEARS    IN    TIJE    MEDICAL    PROFESSION 

former  years.  All  wine  consumed  in  England  is  imported. 
In  the  United  States,  seventy-eig^ht  per  cent,  of  the  wine  used 
is  made  at  home.  This  is  an  important  showing.  Germany 
consumes  25.5  gallons  of  heer  per  capita  per  year,  and  in  this 
there  is  a  tendency  to  increase.  England  consumes  30.7  gal- 
lons of  malt  liquors  per  capita  per  year,  and  the  United  States 
consumes  fifteen  gallons  per  capita  per  year.  The  French, 
among  whom  wine  is  the  national  drink,  consume  five  gallons 
of  beer  per  capita  per  year,  and  beer-drinking  is  increasing 
in  France.  Belgium  consumes  forty-three  gallons  of  beer 
per  capita  per  year,  and  Bavaria  fifty  gallons  per  capita  per 
year,  and  Bavaria  makes  the  best  beer  in  the  world.  Of 
spirits,  Germany  consumes  1.94  gallons  per  capita  per  year. 
France  consumes  1.85  gallons  per  capita  per  year.  England 
consumes  i.oi  gallons,  and  the  United  States  .83  of  one  gal- 
lon per  capita  per  year.  In  Holland  and  Belgium  the  con- 
sumption is  two  gallons  per  capita  per  year.  England  collects 
as  taxes  from  spirits,  wines,  and  malt  liquors  $449,820,000. 
Our  country  collects  $444,116,123.  The  French  govern- 
ment at  large  only  collects  from  these  sources  $102,400,000 
per  year,  but  there  are  other  taxes  by  cities  and  towns,  just 
as  we  have  in  the  United  States,  and  are  not  included  in  the 
general  government  tax.  Germany  only  collects  directly 
$57,969,040.  The  average  German  at  home  or  abroad  rebels 
when  you  tax  his  beer,  for  it  is  the  main-spring  of  his  pleas- 
ure, not  only  of  his  palate,  but  of  his  wdiole  social  life.  The 
old  lady  said  to  her  son,  who  had  left  his  American  home 
to  reside  temporarily  in  Germany,  "  Henry,  I  hope  you  go 
to  church  on  Sundays."  ''  Yes.  mother,"  said  Henry. 
"  Henry,"  said  the  good  mother,  "  I  trust  you  visit  the  pas- 
tor now  and  again  at  his  home."  "  That  is  not  necessary, 
mother,  I  always  meet  and  chat  with  him  at  the  beer-garden 
on  Sunday  after  service." 

I  think  there  is  one  thing  we  may  truthfully  say :  the  con- 
sumption of  spirits  as  a  beverage  is  gradually  declining  in 
this  country,  and  that  mania  a  potu  is  more  and  more  be- 
coming a  rare  disease.     Such  is  my  individual  experience. 

299 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

and  it  has  been  and  still  is  considerable,  having  been  con- 
nected during  much  of  my  professional  life  with  various  elee- 
mosynary and  criminal  institutions  where  such  cases  abound, 
and  I  have  seen  it  in  men  and  women  of  all  colors  and  na- 
tionalities. The  increased  consumption  of  beer  and  wines 
accounts  for  much  of  the  decrease  of  consumption  of  spirits, 
and  it  looks  to  me  as  though  the  coming  man  would  gradu- 
ally cease  to  use  spirits  as  a  beverage,  a  condition  greatly  to 
be  wished  for  truly.  I  think  man  begins  to  realize  the  fact 
that  the  consumption  of  spirits  as  a  beverage  is  the  greatest 
bane  to  his  health  and  happiness  that  lies  in  his  path  of  life. 
Instinct  tells  him  this,  just  as  instinct  teaches  the  lower  ani- 
mals to  avoid  certain  plants  as  poisonous.  The  ancients  in- 
vented spirits  (probably  the  Arabians),  and  I  mean  by  spirits 
the  brandies,  whiskeys,  rums,  gins,  and  such,  not  the  much 
less  harmful  malt  liquors  nor  the  mirth-provoking  mellow 
wine.  The  ancients  used  these  spirits  as  medicine  alone. 
May  we  who  live  after  them,  and  may  those  who  live  after 
us,  gradually  come  to  use  them  in  no  other  way;  and  as 
medicine  may  we  of  the  medical  profession  learn  to  guide  and 
guard  their  use. 

I  add  here  an  important  table  taken  from  an  article  in  the 
University  Medical  Magazine  for  October,  1898,  by  Dr.  B. 
Franklin  Stahl.  The  table  is  by  Roberts,  and  shows  the  re- 
tarding effects  of  wines  and  spirits  on  digestion,  both  pep- 
tic and  salivary  digestion.  Let  me  first  quote  from  Stahl's 
conclusions,  using  his  quotations  from  Chambers,  Osier,  and 
others. 

"  Wines  and  beers,  a  glass  or  two  taken  with  a  meal,  will 
help  gastric  digestion.  When  consumed  in  quantities,  as  not 
infrequently  used,  a  pint  of  claret  or  a  large  amount  of  beer, 
they  retard  digestion  more  or  less.  As  to  time  of  adminis- 
tration, they  should  be  given  with  food,  or  a  part  in  certain 
instances  taken  just  before  food.  Osier  says  the  man  who 
drinks  before  noon  is  lost.  As  a  beverage,  I  say,  a  man 
should  postpone  his  libations  until  the  dinner  hour.  Cham- 
bers says  the  laborer,  whose  limbs  are  stiff  with  his  day's  toil, 

300 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

and  the  brain-worker,  who  still  more  acutely  feels  the  wear 
and  tear  of  bread-winning,  are  not  wasting  the  money  they 
earn  with  which  they  buy  a  fair  ration  of  beer  or  wine  for 
their  evening  meal. 

"  The  malt  liquors  are  indicated  as  fattening  agents,  to 
stimulate  digestion,  and  as  mild  tonics  and  stimulants.  The 
spirituous  liquors  are  required  in  acute  illness,  and  are  bene- 
ficial in  old  age.  The  wines  are  most  useful  in  convalescence 
and  in  those  cases  where  we  are  unable  to  give  the  stronger 
liquors,  because  of  their  unacceptability  to  the  stomach.  Fur- 
thermore, they  have  a  fixed  place  in  our  dietetics.  They  are 
to  be  avoided  in  atheromatous  conditions  of  the  blood-vessels, 
and  particularly  in  angina  pectoris  from  the  free  salts  they 
contain,  and  this  is  why  spirits  is  the  drink  of  old  age 
when  the  blood-vessels  have  deteriorated.  Finally,  consider- 
ing some  special  conditions  where  selection  must  be  made, 
it  may  be  said  that  in  anaemia,  in  conditions  included  under 
the  term  malnutrition,  and  in  convalescence,  you  will  do  well 
to  order  a  good  claret,  Burgundy,  or  Sauterne.  The  lighter 
wines  of  good  quality  are  best  for  daily  consumption  for 
brain-workers  who  lead  sedentary  lives,  and  who  need  a 
digestive  and  stimulant. 

"  You  will  hasten  recovery  in  many  by  ordering  a  light 
luncheon,  accompanied  with  wine,  betw^een  meals.  Gout  is 
regarded  by  many  as  the  child  of  port  w-ine.  Next  in  order 
as  causative  of  gout  comes  champagne,  especially  the  sweet 
wines.  A  gouty  person  should  drink  only  the  dryest  of  the 
dry  champagnes.  Then  come  sherry,  Madeira,  Burgundy, 
and  malt  liquors.  Cider  is  almost  as  potent  in  its  causation 
of  gout  as  are  the  wines.  Some  differ  from  this  assertion, 
as  I  have  explained.  Claret  is  almost  the  only  safe  wine  in 
gout.  I  will  say  that  water  is  safer  and  better  than  any  of 
the  alcoholics.  In  diarrhcea  and  dysentery  you  will  find 
brandy  of  service,  especially  in  the  old.  Claret  is  also  valua- 
ble here ;  in  Germany  and  France  it  is  frequently  used  to  the 
exclusion  of  w-ater.  Very  Httle  water  the  French  and  Ger- 
mans drink,  anyhow.     In  diabetes,  claret  is  safest,  but  Bur- 

301 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

gundy,  hock,  or  dry  sherry  and  some  whiskey  will  be  found 
to  agree.  I  would  say,  drop  the  sherry  of  all  kinds,  and  con- 
fine the  whiskey  to  those  specimens  not  colored  with  caramel. 
In  fever,  if  self -limiting  and  of  moderate  severity,  alcoholic 
stimulants  are  not  indicated  until  convalescence  has  been 
established,  when  they  may  be  given  with  advantage.  You 
may  regard  it  as  an  indication  for  alcohol  when  the  fever  is 
very  high  from  the  outset,  and  the  heart  appears  embar- 
rassed, as  shown  by  a  weak  or  absent  second  sound.  Chronic 
alcoholism,  in  nearly  all  instances,  may  be  successfully  treated 
without  liquor.  When  it  is  required,  it  should  be  given  in 
the  form  of  spirits,  and  in  large  doses.  In  liver  disease  alco- 
hol is  usually  contraindicated.  If  demanded,  claret  or  brandy, 
well  diluted  with  aerated  water,  should  be  chosen.  Insomnia 
is  often  relieved  by  mulled  wine  or  by  whiskey  and  hot  water. 
Beer  is  also  of  service  in  this  connection.  I  need  hardly  say 
there  is  danger  of  the  formation  of  the  habit  under  these  cir- 
cumstances, nor  need  I  remind  you  that  whiskey  is  best  for 
the  old.  In  consumption  the  malt  liquors  are  of  service  early, 
and  the  spirituous  liquors  later  in  the  disease.  Remembering 
that  here,  more  than  in  almost  any  other  disease,  the  diges- 
tion is  of  the  greatest  importance,  you  will  be  governed  en- 
tirely by  the  effect  produced  on  the  digestion.  In  chronic 
rheumatism  and  renal  disease  they  may  only  be  given  when 
the  demand  is  greater  than  the  contraindication,  and  all  the 
while  the  effect  must  be  noted.  Well-diluted  spirits  are  best 
here.  In  scurvy,  malt  liquors  are  especially  serviceable,  yet 
some  do  better  on  claret  or  spirits  and  water. 

"  Now,  while  certain  suggestions  can  be  made  quite  posi- 
tively and  on  well-founded  reasons,  there  must  remain  many 
instances  where  your  individual  judgment  must  come  into 
play.  Whenever  you  prescribe  an  alcoholic,  whether  to  man 
or  to  woman,  whether  to  the  young  or  to  the  old,  remember 
well  and  ponder  well  on  the  terrible  weapon  you  are  using 
both  for  good  and  evil.  I  beg  of  you  not  to  use  it  therapeu- 
tically in  a  reckless  manner,  and  I  pray  God  to  especially 
guide  you  in  prescribing  it  to  the  young  and  susceptible." 

302 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 


5  per  cent 

15  per  cent 

40  per  cent.      .        

50  per  cent 

60  ner  rent 

Wine,  Liquor,  or  Beverage  added. 

135  min. 

180  min. 

Embar- 
rassed. 
300  min. 

Almost   no 
digestion. 

3         3. 

?         ?' 

Proof  Spirit, 
Brandy,  Gin, 
or  Whiskey. 

115  min. 
150  min. 
200  min. 
200  min. 

Embar- 
rassed. 

Almost   no 
digestion. 

J 

180  min. 

200  min. 

Embar- 
rassed. 

3        <-" 

3            3 

8 

7 

9§ 

0                <^ 

S                g. 

3                p 

8 

5' 

140  min. 
180  min. 

8 

3. 

0 

p" 
n 

00 

o 

3. 
3 

100  min. 
130  min. 

3. 
5 

Cham- 
pagne. 

si" 

140  min. 
200  min. 

3. 
3 

Burton 
Ale. 

3 
5' 

3                 3. 

3'                3' 

8 
3. 

Lager 
Beer. 

c 
o 

O 


303 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

TABLE    SHOWING    THE    EFFECT    OF    SHERRY    AND    HOCK    UPON 
SALIVARY   DIGESTION.i     (ROBERTS.) 


Proportion  of  Sherry  or  Hock  contained  in 
the  Digesting  Mixture. 

Sherry. 

Hock. 

8  minutes. 
30  minutes. 
No  action  beyond 

soluble  starch. 
No  action. 
4  minutes. 

16  minutes. 

0.  5     per  cent 

1.  per  cent.                                 

80  minutes. 
No  action  beyond 
soluble  starch.     . 
No  action. 

40.       per  cent.,  neutralized 

4  minutes. 

1  Time  normally  required  equals  four  minutes. 


TABLE    SHOWING    THE    EFFECT    OF    ALCOHOL,    BRANDY,    AND 
WHISKEY   ON   SALIVARY   DIGESTION. ^     (ROBERTS.) 


Proportion  of  Proof  Spirit, 

Brandy,  or  Whiskey 
in  the  Digesting  Mixture. 

Proof  Spirit. 

French  Brandy. 

Scotch  Whiskey. 

5  per  cent 

10  per  cent 

20  per  cent 

40  per  cent 

60  per  cent 

70  per  cent 

90  per  cent 

4  minutes. 

4  minutes. 

4  minutes. 

8  minutes. 
14  minutes. 
20  minutes. 
Very  slow  action. 

4  minutes. 
Very  slow  action. 
No  action. 
No  action. 
No  action. 
No  action. 
No  action. 

4  minutes. 
30  minutes. 
Very  slow  action. 
No  action. 
No  action. 
No  action. 
No  action. 

2  Time  normally  required,  four  minutes. 


Fruits  and  Nuts  as  Articles  of  Diet. — There  are  few  things 
of  more  importance  for  the  physician  to  know  and  under- 
stand than  the  composition  of  foods,  their  effects  upon  the 
system,  and  the  philosophy  of  the  physiology  of  metabolism, 
including  katabolism  and  anabolism.  There  is  great  defect 
in  the  teachings  of  the  day  in  our  medical  schools  in  regard  to 
these  matters,  and  whilst  they  have  advanced  considerably 
in  recent  years,  there  is  yet  great  room  for  betterment  and 
improvement. 

304 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

A  j^lcince  at  the  accompanying  tables  will  show  the  value 
of  fruit  as  food  from  the  economic  stand-point. 


VARIOUS   SUBSTANCES. 


Waste 

from  loo 

pounds  as 

purchased. 


Edible  Dry 

Matter  in  loo 

pounds  as 

purchased. 


Cost  of  one 
pound  of 

Edible  Dry 
Matter. 


Fuel  value 

of  one 
pound  as 
purchased. 


Potatoes 

Wheat  flour 

Corn-meal  (bolted)  .    . 

Oatmeal 

Milk 

Fresh  codfish      .... 
Hind-quarter  of  fat  beef 

Fowl 

Oysters 


Pounds. 

15- 


29.9 
14. 1 
30. 


Pounds. 
17.9 

87.5 
87.1 
92.8 

13- 

11. 6 

35-9 
24.4 

11. 7 


2.8 
3-5 

2-3 

6.7 
17.7 
34-5 
33-3 
61.5 
150. 


325 
1640 

165s 
i860 

325 
205 

"35 
680 

23s 


FRUITS. 


Waste 

from  100 

pounds  as 

purchased. 


Edible  Dry 

Matter  in  100 

pounds  as 

purchased. 


Cost  of  one        Fuel  value 

pound  of  I         of  one 

Edible  Dr>'  '      pound  as 
Matter.  purchased. 


Apples    .    .  . 

Apricots     .  . 

Blackberries  . 

Grapes    .    .  . 

Pears  .    .    .  . 

Plums     .    .  . 

Raspbenies  . 

Strawberries  . 

Averagre 


Pounds. 
25. 

6. 

25- 
25- 

4.8 


Pounds. 

13-5 
14. 1 
10.5 

15-9 
12. 1 
20.6 
14.2 
8.2 


8.4 
21.4 
76. 
19. 

12.5 
20.2 

49-3 
98.3 


225 
225 
245 
320 

235 
370 
255 
155 


12.4 


:!8.I 


256 


30  = 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 
VEGETABLES. 


Beets 

Cabbage  .  .  . 
Carrots  .... 
Lettuce  .... 
Onions  .... 
Parsnips  .  .  . 
Green  peas  .  . 
Pumpkin  .  .  . 
Rutabaga  turnips 
Squash  .... 
Tomatoes  .    .    . 

Average    . 


Waste 

from  loo 

pounds  as 

purchased. 


Pounds. 
20. 

15- 
20. 
18. 
10. 
20. 

SO- 
SO- 
SO. 


Edible  Drj' 

Matter  in  100 

pounds  as 

purchased. 


Pounds. 
10. 


Copt  of  one 
pound  of 

Edible  Dry 
Matter. 


6.6 
18.3 

9- 
102. 

19- 
9- 

72.8 

30. 

7.8 

37-3 
22.3 


Fuel  value 

of  one 
pound  as 
purchased. 


170 
140 
170 

8S 
210 
285 
200 

60 

13s 
125 

loS 


25-7 


30.3 


^53 


These  are  Professor  W.  H.  Jordan's  tables,  and  are  valu- 
able from  the  stand-point  of  the  chemist  and  of  the  economist. 
The  tables  show  that  fruits  cost  about  ten  times  as  much 
as  flour,  corn-meal,  and  such  articles,  taking  into  considera- 
tion their  food  values;  therefore  there  must  be  found  other 
considerations  than  that  of  food  value  for  prescribing  and 
eating  fruits.  Fruits  have  long  been  a  great  part  of  the  diet 
of  the  older  races,  and  of  the  semi-civilized  and  savage  tribes. 
The  latter,  especially  those  of  the  tropics  and  temperate  lati- 
tudes, live  on  fruits,  fish,  and  starchy  vegetables,  and  these 
people  are  usually  healthy,  strong,  and  vigorous,  and  were 
more  so  until  their  more  civilized  and  enlightened  brothers 
introduced  among  them  the  various  seductive  poisons  of  a 
higher  civilization.  As  a  rule,  with  fruit  we  take  much  bulk 
that  is  not  nutritious,  and  this  very  bulk  is  useful  because  it 
prevents  us  eating  too  much  of  the  stronger  articles  of  diet. 
Given  fruit  as  the  first  course  at  breakfast,  and  we  will  not 
be  so  apt  to  overload  our  stomachs  with  buckwheat  cakes 
and  sausages,  and  the  fruit  taken  will  in  many  ways  help  us 

306 


FORTY    YEARS    IN    THE    MEDICAT.    PROFESSION 

to  get  Cfjnifortably  rid  of  the  grentcr  burden,  the  sugars  and 
acids  of  the  fruit  course  being  the  factors  here.  The  aroma 
of  the  fruits  is  ])leasing  to  the  senses,  and  thus  aids  secretion 
in  various  forms,  especially  of  the  digestive  juices. 

Taking  this  view  of  the  matter,  fruit  is  better  taken  with 
the  meal,  and  before  the  meal  rather  than  after  the  meal. 
During  the  meal  especially  we  crave  condiments  or  some- 
thing to  cater  to  our  taste  and  bring  out  a  j^-oper  secretion  of 
the  digestive  juices  and  ferments,  and  to  accomplish  this  we 
eat  cranberry  with  our  turkey,  currant  jelly  with  our  roast 
mutton,  capers  with  our  boiled  mutton,  roast  apple  with  our 
goose,  and  apple-sauce  with  our  roast  pork.  A  good  scien- 
tific reason  for  eating  these  fruits  is  that  the  fats  of  the  meats 
with  which  they  are  eaten  are,  as  a  rule,  neutral  fats ;  that  is 
to  say,  they  have  not  sufficient  acid  in  them  to  cause  the  alka- 
line bile  and  pancreatic  fluid  to  emulsify  these  fats,  and  the 
fruit  acids  here  make  up  the  deficiency  in  nature.  What  a 
teacher  nature  is,  anyhow  ! 

Fruits  contain  much  water,  and  the  general  make-up  is 
finished  with  sugars,  starches,  the  gelatinous  substance  called 
pectin,  acids,  and  cellulose,  the  cellular  tissue,  composed  of 
carbon,  hydrogen,  and  oxygen.  When  fresh  they  are  mark- 
edly antiscorbutic  and  appetizing.  Pectin  is  a  carbohydrate, 
and  the  quince  contains  a  large  amount  of  it,  making  it  espe- 
cially good  for  jelly.  The  acids  of  fruits  are  the  citric,  the 
tartaric,  especially  in  the  grape,  and  the  malic,  which  exists 
largely  in  the  apple  particularly.  The  organic  acids  are  in 
union  with  alkalies,  and  these  form  salts,  and  these  salts  are 
split  up  in  the  system  and  leave  the  alkalies  free,  which  usu- 
ally combine  and  form  carbonates  or  phosphates  with  acids 
found  in  the  body. 

Again,  this  is  a  fact  of  great  importance  both  practically 
and  scientifically.  Why  do  we  give  lemon- juice  and  expect 
benefit,  in  rheumatic  fever  for  instance,  when  the  blood  is  so 
acid  already  that  the  profuse  perspirations  change  litmus  blue 
to  red  almost  by  their  fumes  before  contact?  A\'e  can  answer, 
in  giving  lemon- juice  in  such  cases,  or  any  other  fruit- juice, 

307 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

we  do  not  give  it  as  an  acid  to  increase  the  already  over-acid 
condition  of  the  blood.  We  give  it,  paradoxical  as  it  may 
appear,  as  an  alkali  to  increase  the  alkalinity  of  the  blood, 
bringing  this  about  by  the  citric  acid  of  the  lemon  being 
combined  with  salts,  and  these  salts  splitting  up  and  reappear- 
ing as  carbonates  and  phosphates,  and  these  reducing  the 
acidity  of  the  blood,  and  thus  aiding  the  return  to  health  of 
the  rheumatic  condition.  Even  if  the  citric  acid  of  the  lemon 
is  free,  it  meets  salts  in  the  system,  and  does  the  same  good 
in  a  more  direct  way.    This  matter  is  all  important. 

Dr.  Hoy  has  launched  a  tirade  against  fruit  as  an  article  of 
diet,  simply  because  it  is  an  acid  diet,  as  he  claims,  and  de- 
stroys the  alkalinity  of  the  blood.  Hoy  claims  that  fruits  are 
mostly  sugar  and  water,  and  this  mixture  ferments  easily  and 
destroys  digestion.  He  claims  that  digestion,  especially  diges- 
tion below  the  stomach,  is  accomplished  in  alkaline  surround- 
ings and  in  alkaline  media,  and  the  acid  in  fruits  eaten  de- 
stroys this  alkalinity  and  thus  interferes  with  digestion,  and 
therefore  that  fruit  is  improper  diet  in  most  instances.  I 
think  we  have  shown  that  it  does  no  such  thing,  and  that  the 
fruit  acids,  both  combined  and  free,  are,  by  the  time  they  reach 
the  point  of  intestinal  digestion,  in  a  condition  not  of  acidity 
to  render  the  surroundings  acid,  but  are  neutral  or  alkaline, 
and  in  this  way  help  digestion,  as  they  undoubtedly  do  even 
if  they  do  not  contain  a  special  digestive  ferment,  like  the 
pine-apple,  called  bromelin,  which  has  the  property  of  convert- 
ing albuminoids  into  peptones.  The  juice  of  the  papaw  has 
the  same  power,  even  in  a  greater  degree  than  the  pine-apple, 
and  doubtless  many  more  fruits  have  juices  with  this  power, 
if,  indeed,  all  fresh  fruit-juice  does  not  have  it  to  some  degree 
greater  or  less.  The  prune  and  the  fig  and  such  fruits  he 
condemns  as  causing  by  their  coarse  skins  and  seeds  bowel 
irritations.  More  likely  nature  has  provided  just  such  fruits 
for  these  special  purposes  for  man,  and  instead  of  condemning 
them  it  is  our  duty  to  learn  all  about  them  and  use  them  in 
the  proper  cases.  The  fig,  the  date,  the  prune,  and  such  fruits 
are,  indeed,  most  useful  fruits. 

308 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

Hoy  says  aj^ain,  in  his  opposition  to  fruits  as  food  for  man, 
that  the  intestinal  juices  do  not  act  on  starch,  albuminoids, 
and  fats,  but  act  on  tlie  maltose  marlc  frmn  the  starch  by  the 
saliva  and  pancreatic  juice,  and  on  all  forms  of  sugar,  which 
may  have  been  taken  with  the  food.  They  convert  these  into 
glucose.  The  media  in  which  this  conversion  occurs  must  be 
alkaline.  Acid  destroys  this  action,  therefore  acid  in  fruit 
eaten  stops  it.  Yes,  it  would  if  it  was  present  as  free  acid, 
but  it  is  not  present  as  free  acid,  but  is  combined  with  bases 
in  the  form  of  salts,  and  has  an  alkaline  effect.  Again,  the 
small  intestines  transfer  the  digested  matters  in  them  into  the 
blood.  By  their  epithelial  cells  they  change  peptone  into 
serum  albumin  and  glol)ulin,  and  as  these  they  enter  the 
blood,  and  here  the  media  must  be  alkaline,  and  therefore 
fruit-eating  is  against  this  process.  I  say  again,  fruit  rather 
helps  along  the  alkaline  surroundings,  does  not  either  check 
them  or  stop  them,  and  is  therefore  beneficial.  There  is  one 
condition  where  it  is  wrong  to  eat  much  fruit,  especially 
wrong,  such  a  fruit  as  apples,  for  example.  If  such  be  eaten 
after  a  hearty  dinner,  where  much  starchy  matter  like  rice 
and  potatoes  has  been  eaten,  acid  indigestion  will  surely  fol- 
low, because  the  fermentation  has  been  hurried  by  the  combi- 
nation of  the  fruit- juice  and  the  excess  of  starch.  A  little 
soda  or  potash  will  soon  correct  this  temporary  trouble.  That 
"  fruit  is  gold  in  the  morning,  silver  at  noon,  and  lead  at 
night"  is  not  altogether  true,  but  will  serve  somewhat  as  a 
guide  in  our  eating  it. 

Hoy  gives  the  following  as  definitions  of  fruits  and  vege- 
tables. "  All  succulent  fruits  produced  by  annual  plants,  as 
well  as  the  stalks,  roots,  leaves,  and  tubers  of  any  plant  used 
by  man  as  food,  are  vegetables.  All  succulent  fruits  produced 
by  perennial  or  biennial  plants,  and  used  as  food,  are  fruits. 
The  ripened  edible  seeds  of  leguminous  and  graminaceous 
plants  are  vegetable  food,  as  are  also  nuts,  which  are  the  dry, 
oleaginous,  or  starchy  fruits  of  perennial  plants,  in  which  the 
epicarp  is  liquefied."  He  speaks  of  fruit  as  acid  and  of  vege- 
tables as  not  acid.     ]\Iany  vegetables  contain  acid,   as  the 

309 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

spinach  with  its  oxalic  acid,  the  cabbage  with  a  Httle  of  the 
same,'  and  the  rhubarb  with  a  great  deal.  The  tomato  has 
acid,  much  of  it  at  times,  but  by  its  continued  evolution  from 
the  realm  of  the  vegetable  to  that  of  the  fruit,  it  may  be  well 
to  pause  in  classifying  it,  so  rapid  is  its  transformation  to  the 
fruit  list  approaching.  Fruits  contain,  some  of  them,  a  little 
fat  and  waxy  matter,  as  the  olive,  but,  as  a  rule,  sugars  and 
starches  predominate,  with  a  very  little  nitrogen  in  the  shape 
of  vegetable  albumin.  Their  aroma  and  flavor  are  given  by 
various  essential  oils  and  compound  ethers  inherent  in  them 
and  generated  in  the  ripening  of  the  fruit.  The  mangosteen 
of  Borneo  and  the  durian  of  Java  are  said  to  hold  these  above 
all  others  and  to  be  the  most  luscious  of  all  fruits.  From  the 
latitude  in  which  they  are  raised,  they  are  evidently  sweet 
fruits.  The  cultivation  of  sour  fruits,  whether  in  a  temper- 
ate or  a  hot  climate,  reduces  the  acid  in  them  and  improves 
their  aroma  and  flavor.  There  is  one  thing  always  to  remem- 
ber in  eating  fruit  of  any  and  all  kinds, — they  are  invariably 
an  inviting  host  for  all  pathogenic  and  other  germs,  and 
should  never  be  eaten  until  the  outer  skin  has  been  removed 
or  until  they  have  been  thoroughly  washed  and  cleansed.  The 
boys'  green-apple  bellyache  comes  as  often  from  the  patho- 
genic germs  that  go  down  with  his  apples  as  from  any  indi- 
gestible properties  pertaining  to  the  fruit  he  has  eaten. 

A  good  anecdote  is  told  of  the  great  Pasteur,  who  above  all 
other  men  probably  knew  of  the  risks  we  run  from  taking  in 
pathogenic  germs  with  our  food.  Pasteur  was  dining,  and 
among  other  things  cherries  were  served  with  the  fruit.  Pas- 
teur was  very  careful  to  thoroughly  wash  his  cherries  before 
eating  them,  and  delivered  quite  a  lecture  on  pathogenic 
germs  and  their  dangers,  to  those  about  the  table,  among 
whom  were  several  children.  The  dinner  finished,  Pasteur, 
wanting  water,  in  the  absent-minded  way  often  attributed 
to  great  men,  quaffed  off  the  water  in  which  he  had  washed 
his  cherries,  and  the  children  chaffed  him  in  great  glee.  Here 
were  two  object-lessons  in  nature  study,  one  on  absent-mind- 
edness, and  one  on  pathogenic  germs. 

310 


FORTY    YEARS    IN    THI-:    MJ-.DICAL    PROFESSION 

Fruits  arc  iisiially  classified  as  stone  fruits,  pomes,  f>r  the 
fleshy  fruits,  Hkc  tlic  ;ii)|)lc  or  pear,  berries,  ca])sules,  or  C(jv- 
ered  fruits,  and  the  pepos,  or  melon  family.  Some,  like 
the  banana  and  the  date,  will  support  life  for  a  \on^  time  on 
account  of  the  great  amount  of  sugar  in  them ;  others,  like 
the  pear  and  the  api)lc,  are  hcl])S  in  the  general  diet;  and 
others  again  have  less  nutritive  value  than  these,  but  have 
their  uses  as  appetizers  and  digesters,  as  the  papavv  and  the 
pine-apple.  Thompson  sums  up  the  uses  of  fruits  in  the  ani- 
mal economy  as  follows : 

To  furnish  nutriment. 

To  convey  water  to  the  system  and  relieve  thirst. 

To  introduce  various  salts  and  organic  acids,  which  im- 
prove the  quality  of  the  blood  and  react  favorably  upon  the 
secretions. 

As  antiscorbutics. 

As  diuretics,  and  to  lessen  the  acidity  of  the  urine.  They 
do  this  owing  to  the  decomposition  of  various  alkaline  salts 
in  the  blood  or  tissues,  which  are  reformed  into  alkaline  car- 
bonates, and  as  such  are  excreted.  For  this  reason  fruit  is 
good  for  gout  and  the  gouty  diathesis,  because  it  prevents  the 
accumulation  of  acid  urates. 

As  laxatives  and  cathartics. 

To  stimulate  the  appetite,  improve  digestion,  and  give  vari- 
ety in  the  diet. 

As  special  cures  for  certain  diseases,  like  the  grape-cure, 
although  their  specific  action  is  very  doubtful. 

The  apple,  lime,  lemon,  and  orange  have  much  potash,  lime, 
and  magnesia  in  their  composition,  and  are  the  antiscorbutic 
fruits  par  excellence.  Peaches  may  be  added  to  these.  The 
most  nutritious  fruits  are  the  sweet  and  starchy  fruits,  and 
are  the  banana,  the  fig,  the  date,  the  plum,  and  the  grape. 
The  most  watery  of  fruits  are  the  melons,  the  citrus  fruits, 
as  oranges,  limes,  lemons,  and  shaddocks,  together  with 
grapes. 

The  ripening  of  fruit  is  an  interesting  process.  The  ab- 
sorption of  oxygen  by  the  fruit  has  much  to  do  with  it.     The 

311 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

contained  acids  and  the  tannin  are  altered  by  this  as  time 
goes  on  and  the  astringency  and  acidity  of  the  fruit  decrease, 
the  starch  going  into  levulose  or  ghicose,  and  the  gelatinous 
pectin  is  formed.  Now,  with  these  the  volatile  ethers  and  oils 
appear,  and  the  fruit  is  ripe,  or  fit  to  eat,  and  this  holds  and 
this  ripe  condition  increases  until  the  fermentations  of  decay 
start  up  and  the  fruit  returns  again  to  its  original  elements, 
just  as  do  all  other  organic  bodies. 

Thompson  gives  the  most  digestible  fruits  as  grapes,  or- 
anges, lemons,  cooked  apples,  figs,  peaches,  strawberries,  and 
raspberries.  I  look  upon  strawberries  and  raspberries  as 
rather  gouty,  from  the  less  tendency  of  their  acids  to  com- 
bine with  bases  during  digestion,  and  thus  leaving  more  free 
acid  than  other  fruits  to  disturb  the  alkalinity  of  the  blood. 
Not  so  digestible  as  the  other  fruits  in  the  list  given  are 
melons,  prunes,  plums,  raw  apples,  pears,  apricots,  bananas, 
and  fresh  currants.  Of  course,  in  all  this  much  depends  upon 
the  condition  of  the  fruit  as  to  ripeness,  etc.,  and  the  idiosyn- 
crasy of  the  individual.  The  most  useful  fruits  for  invalids 
are  oranges,  lemons,  baked  apples  and  pears,  stewed  prunes, 
grapes,  and  the  meal  made  from  the  banana,  but  not  the  fresh 
banana ;  it  is  too  sweet  and  too  starchy. 

Fruit-juices  I  have  spoken  of,  and  of  fruit-syrups,  which 
are  much  used,  and  are  made  either  from  the  fresh  fruit  or 
from  the  prepared  fruit- juices;  both  are  equally  good  when 
the  materials  are  in  proper  condition.  Lemonade,  orange- 
ade, raspberryade,  raspberry  vinegar,  and  such  compounds 
are  much  used,  and  should  be  made  from  the  juices  of  the 
fresh  fruit,  when  obtainable,  especially  lemonade.  Circus 
lemonade  is  made  from  citric  and  tartaric  acid  and  colored 
with  probably  some  aniline  dye  to  make  it  pretty.  Such  a 
drink  has  no  call  for  either  the  sick  or  the  well.  For  the  sick, 
lemonade  and  orangeade  made  from  the  effervescing  waters 
are  among  the  best  and  most  invigorating,  and  such  drinks 
should  not  be  overlooked. 

Dried  fruits  are  fruits  from  which  the  water  has  been  ex- 
pelled either  by  the  sun  or  by  artificial  heat,  and  are  preserved 

312 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

l)y  their  own  sugar  or  glucose.  Most  of  these  are  bleached 
by  sul])hur  fumes.  Whilst  this  may  do  no  great  harm  to 
them  as  articles  of  food,  it  surely  can  do  no  goofl,  and  is  a 
trick  of  the  trade  that  should  be  stopped. 

Preserves  we  are  all  familiar  with.  They  are,  .as  a  rule, 
indigestible,  containing  a  large  excess  of  sugar,  and  are  more 
and  more  being  superseded  by  canned,  tinned,  or  bottled 
fruits.  Here  the  fruits  are  heated  to  destroy  the  bacteria 
present  in  them  and  then  are  hermetically  sealed,  and  will 
keep  in  this  condition  just  so  long  as  no  fresh  air  enters  to 
bring  new  bacteria  among  them  to  set  up  fermentation.  Re- 
member one  point :  after  a  tin  can  has  been  opened,  imme- 
diately empty  it  and  keep  the  contents  until  used  in  a  china 
or  glass  bowl.  If  left  in  the  can  the  contents  soon  become 
poisonous  and  unfit  for  food. 

The  very  finest  and  best  of  the  fruits,  and,  in  fact,  all  other 
articles  of  food  preserved  in  this  way,  are  those  done  up  in 
glass.  They  are  probably  more  expensive,  but  are  in  every 
way  safer,  for  there  are  many  reasons  why  metal  cans  and 
metal  soldering,  together  with  the  acids  of  the  contents,  may 
react  on  the  consumers  and  produce  metallic  poisoning,  espe- 
cially lead  poisoning.  The  competition  in  trade  causes  many 
of  the  canners  to  use  low-grade  tin,  the  tern  plate,  which  is 
little  more  than  iron  with  a  coating  of  lead ;  indeed,  in  this 
quality  of  metal  there  is  little  or  no  tin,  and  if  the  cans  are 
recklessly  soldered  so  the  solder  may  enter  and  mingle  with 
the  contents,  then  doubly  unfortunate  are  those  who  con- 
sume it.  Remember,  as  to  all  preserved,  canned,  or  other- 
wise treated  fruits,  they  lack  the  elements  of  freshness,  and 
for  some  unexplained  reason  they  are  not  nearly  so  useful  as 
antiscorbutics  as  are  the  fresh  fruits  or  vegetables. 

To  show  the  importance  of  fruit  to  the  American  people 
as  a  part  of  their  diet,  let  me  give  a  short  review,  the  facts 
for  which  I  obtain  from  government  publications  and  my  own 
experience.  The  early  colonists  found  here  many  wild  fruits, 
berries,  grapes,  and  nuts.  From  these  selections  were  made, 
and  these  were  cultivated  and  improved,  and  foreign  slips  and 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

cuttings  were  planted  and  grafted.  In  1821  about  three  mil- 
lions of  pounds  of  dried  fruits  were  imported.  Apples  were 
the  first  fruit  we  exported  successfully.  John  Bartram,  of 
Philadelphia,  the  well-known  originator  of  Bartram's  Garden 
in  that  city,  a  part  of  which  is  the  Eastwick  property  at  Gray's 
Ferry,  and  I  think  is  now  a  public  park,  grew  on  these  grounds 
the  well-known  Newtown  pippin  apple,  which  he  successfully 
exported  to  England  by  sailing  vessels,  the  trip  consuming, 
on  an  average  for  the  eastern  voyage,  forty  days.  In  1821 
we  imported  over  two  millions  of  pounds  of  raisins.  In  1894 
California  alone  exported  one  hundred  and  three  millions  of 
pounds. 

It  is  not  generally  known  that  the  dried  currant  as  im- 
ported is  not  a  true  currant,  but  is  a  small  seedless  raisin  from 
Greece.  They  can  be  grown  and  cured  in  California,  but 
the  business  is  not  very  profitable.  Plums  are  growing  to  be 
a  large  item  of  fruits  in  this  country,  and  prunes  are  already 
a  very  large  item,  and  are  rapidly  driving  out  the  foreign 
product.  In  1896  California  produced  over  fifty-five  million 
pounds.  Figs  are  now  being  raised  and  cured  in  this  country 
in  quite  large  quantities.  In  Mississippi  and  in  Louisiana 
cjuite  a  number  are  packed,  and  in  California  the  original  old 
Black  Mission  fig,  grown  there  as  such  for  over  one  hundred 
years,  is  being  replaced  by  trees  of  the  Smyrna  and  Italy 
varieties,  and  the  fig  industry  is  prospering.  California  pro- 
duces now  over  a  million  dollars'  worth  per  year.  Dates  are 
not  as  yet  grown  commercially  in  this  country,  nor  are  tama- 
rinds. 

The  citrus  fruits  are  grown  very  largely  in  Florida,  Cali- 
fornia, and  Arizona,  and  some  in  Louisiana.  Previous  to 
the  serious  damage  to  the  trees  in  Florida  in  1894  and  1895, 
the  Americans  controlled  the  market  in  the  United  States. 
In  1894  Florida  grew  five  million  boxes,  and  in  1900  they 
hope  to  again  have  a  large  crop,  barring  accidents  from  frost. 
The  Florida  oranges,  considering  the  care  and  attention  given 
to  them  in  selection  and  cultivation,  are  doubtless  the  finest 
of  any  in  the  world.     The  California  oranges  are  chiefly  of 

314 


FORTY    YEARS    IN    TIN':    MIOUICAL    PROFESSION 

the  Bahia  variety,  or,  as  otherwise  called,  the  Washington 
navels  and  Riverside  navels.  California  can  ship  nov^  four 
million  boxes  of  orang'es  annually.  This  is  indeed  a  won- 
derful State.  I  have  been  on  the  summit  of  the  Sierra 
Nevada  Mountains  and  could  have  jumped  into  a  snow- 
bank that  would  have  buried  me  many  times  over  my  head. 
In  two  hours  by  rail  you  could  land  and  i)ick  oranges  and 
lemons  from  the  trees  and  see  the  palms  flourishing  in  the 
open  air. 

Australia  is  a  great  fruit  country.  The  pine-apple,  the 
grape,  and  the  banana  are  grown  in  Queensland.  The  grape, 
the  orange,  the  apple,  and  the  peach  are  grown  to  perfection 
in  New  South  Wales  and  South  Australia.  Western  Austra- 
lia is  a  great  grape  country.  In  Tasmania  they  raise  among 
the  finest  apples  and  pears  of  the  world,  and  ship  them  to 
Europe  in  cold  storage  successfully.  The  strawberries,  rasp- 
berries, currants,  and  gooseberries  of  Tasmania  are  also  noted. 
My  friend.  Dr.  H.  Benjafield,  of  Hobart,  Tasmania,  is  one  of 
the  great  Australian  authorities  on  fruit,  and  is  an  accom- 
plished gentleman.  If  we  reflect,  we  see  that  when  the  trees 
of  Australia  are  in  bloom,  our  trees  here  are  about  maturing 
their  crop,  and  vice  versa,  they  being  about  as  far  south  of 
the  equator  as  we  are  north  of  it.  When  their  fruit  arrives 
in  Europe  or  in  the  United  States  most  of  our  crop  of  the 
year  has  been  consumed.  In  the  Australian  countries  fruit 
is  so  abundant  that,  in  the  season,  pine-apples  can  be  pur- 
chased at  three  cents  apiece.  United  States  money,  grapes  for 
from  five  to  six  cents  per  pound.  Mandarin  oranges  for  one 
cent  per  dozen,  and  bananas  for  from  two  to  four  cents  per 
dozen. 

In  Australia  the  consumption  of  fruits  by  all  classes  of 
people  is  enormous,  and  thoroughly  explodes  the  idea  that 
fruit  causes  general  intestinal  disturbances  and  is  unhealthy. 
The  death-rate  in  these  countries  is  very  low.  There  are 
luncheon  shops  in  all  of  the  towns  of  Australia,  Tasmania, 
and  New  South  Wales  where  fruit  is  given,  all  one  can  eat, 
with  a  cup  of  tea,  coffee,  or  milk,  for  from  ten  to  twelve 

31S 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

cents.  These  shops  are  used  by  all  classes  for  the  mid-day 
meal,  and  the  people  patronizing  them  are  usually  strong  and 
healthy.  In  summer  the  weather  is  very  hot,  and  fruit  ices 
are  used  to  a  large  extent.  There  are  many  of  what  are 
called  tea-rooms,  for  women  exclusively;  the  attendants  are 
women,  who  in  their  black  dresses,  white  aprons,  and  white 
caps  have  a  neat  and  attractive  look.  In  these  rooms  six 
cents  is  paid  for  a  cup  of  tea  or  coffee,  with  bread  and  butter 
and  all  the  fruit  they  can  eat.  I  mention  these  matters  here 
because  I  think  physicians  should  encourage  such  arrange- 
ments for  both  men  and  women  in  this  country,  for  the  Aus- 
tralian people  are  a  strong,  vigorous,  sober,  intelligent,  and 
progressive  race,  and  this  strength  and  vigor  comes,  very 
much  of  it,  from  their  environment  and  from  the  great  quan- 
tities of  fruits  and  meats  they  so  notably  consume.  In  giving 
fruit  with  bread  and  butter  and  cereals,  use  the  sweeter  and 
subacid  fruits  to  the  exclusion  of  the  very  acid  or  sour  fruits. 
The  very  acid  fruits  may  affect  digestion  of  the  starch  in  the 
bread  and  cereals,  as  they  may  not  be  sufficiently  combined 
with  bases,  but  contain  too  much  free  acid.  When  the  sys- 
tem appears  to  crave  acids,  eat  sour  fruit,  do  not  drink  vine- 
gar and  such. 

As  to  the  peculiar  medicinal  properties  of  some  nuts  and 
fruits,  almonds  are  credited  with  giving  brain-power,  juicy 
fruits  give  the  higher  brain-  and  nerve-power,  apples  give  the 
brain  rest,  prunes  are  nerve  sedatives.  There  are  fruit-cures, 
and  several  centuries  ago  medical  men  became  enthusiastic 
over  their  medicinal  virtues,  and  grapes  and  strawberries  to 
the  amount  of  many  pounds  a  day  were  recommended  to  be 
eaten.  Here  certainly  was  an  opportunity  for  nettle-rash  to 
get  in  its  work,  and  for  the  vasomotor  system  to  become  em- 
barrassed. 

The  grape-cure,  not  only  for  the  indigestions,  but  for  va- 
rious other  ailments,  is  carried  on  at  the  present  time  to  a 
considerable  extent.  Many  persons  flock  every  season  to 
the  Rhine  vineyards,  or  to  Italy  and  the  south  of  France,  to 
take  the  grape-cure  for  from  six  weeks  to  two  months,  and 

316 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

are  expected  for  that  Icii^^li  of  time  to  eat  from  five  to  ten 
pounds  of  grapes  daily.  Grapes  are  fattening,  and  hence  are 
good  for  tlic  tuberculous  and  dyspeptics,  and  they  are  also  of 
service  to  the  neurastiienics.  The  gra[ies  must  be  thoroughly 
ripe  and  of  the  best  (quality.  Sour  gravies  are  said  to  have 
the  opposite  effect.  "  The  fathers  have  eaten  sour  grapes,  and 
the  children's  teeth  are  set  on  edge." 

The  various  pathogenic  and  other  germs  of  the  alimentary 
canal  are  said  not  to  thrive  at  all  in  fruit-juices,  and  this  is 
given  as  the  secret  of  the  success  of  the  various  fruit-cures. 
There  is  another  way  to  look  at  it.  Those  who  take  these 
cures  are  generally  high  livers,  are  from  among  the  Carlsbad 
people,  and  the  fruit-cure  to  them  is  semistarvation,  and  semi- 
starvation  to  them  is  just  what  they  need  for  restoration  to 
health.  A  course  at  Carlsbad  is  about  one  and  the  same  thing 
with  grape-cure. 

The  physician  should  never  tire  of  nature  study,  and  before 
I  pass  to  special  fruits  let  me  give  some  views  of  Dr.  Boiling 
W.  Barton,  of  Johns  Hopkins,  on  "  Why  the  leaves  turn  color 
and  fall." 

Dr.  Barton  says  the  leaves  of  most  of  our  trees  fall  in  the 
autumn  because  it  would  be  poor  economy  on  the  part  of  the 
tree  to  retain  them.  They  would  catch  the  snows  and  ices  of 
winter  and  thus  break  the  limbs  of  the  trees  by  this  extra 
accumulated  weight.  The  evergreens  hold  their  leaves  in 
winter;  such  are  tough  and  leathery  or  reduced  to  needles 
like  the  pines.  Most  trees  shed  their  leaves  by  an  act  of  am- 
putation, or  sloughing,  and  cover  the  scar  with  a  layer  of 
cork,  which  stops  bleeding  and  excludes  germs.  In  the  fall 
they  assume  the  splendid  colors  of  autumn  foliage.  This 
change  in  color  has,  so  far  as  is  known,  no  special  biological 
significance;  it  is  a  mere  incident  in  the  later  life  and  death 
of  the  leaves.  Color  in  flowers  makes  of  them  organs  of  al- 
lurement to  insects,  birds,  etc.,  which  visit  them  for  their 
honey,  and  in  return  render  service  in  pollination.  Color  in 
fruit  makes  it  conspicuous,  and  secures  free  transportation  by 
sundry  animals,  which  thus  scatter  the  seed.    The  hues  of  au- 

317 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

tumn  foliage  mean  little  more  in  the  lives  of  the  plants  than 
does  the  color  of  precipitates  in  the  test-tubes  of  the  chemist. 

To  understand  these  color  changes  in  the  dying  leaf  we 
must  know  something  of  the  purpose  and  functions  of  healthy- 
active  leaves.  This  function  is  not,  as  is  often  said,  to  give 
shade,  whether  to  the  plant  itself  or  to  man  or  beast.  If  they 
shade  the  roots  and  so  economize  water,  this  is  only  by  the 
way,  and  not  the  important  role  they  play  in  the  life  of  the 
plant.  The  plant  gets  its  food  from  the  earth  and  the  air. 
These  are  the  raw  materials,  salts  of  the  soil  dissolved  in 
water,  and  oxygen  and  carbonic  acid  gas  free  in  the  atmos- 
phere. These  simple  substances  are  received  in  the  leaves 
and  spread  out  with  the  green  substances  of  the  leaf-cells  to 
the  action  of  the  sun's  rays,  and  are  thus  converted  into  the 
complex  organic  products  upon  which  the  plant  depends  for 
its  growth  and  upon  which  animals  can  live.  The  leaf-green 
or  chlorophyll  is  the  substance  upon  which  all  this  compli- 
cated chemistry  depends,  and  has  therefore  been  spoken  of 
as  the  most  important  of  all  known  compounds,  for  life,  as 
we  know  it,  could  not  exist  without  it.  Without  light  and  a 
certain  high  temperature  the  chlorophyll  would  avail  nothing. 

Leaves  may  be  likened  not  inaptly  to  a  factory  operating 
only  in  summer  time,  when  the  sun  is  bright  and  the  air  warm. 
Then  it  is  that  a  number  of  definite  products  are  manufac- 
tured and  transported  back  through  leaf-stalk  and  stem  to 
parts  where  they  may  be  immediately  needed  for  growth,  else 
to  be  stored  for  future  use.  As  autumn  comes  on  the  nights 
grow  chill  and  conditions  become  unfavorable;  preparations 
are  set  on  foot  to  stop  work  and  to  destroy  the  factory.  At 
this  period  the  factory  is  more  or  less  filled  with  manufactured 
goods  and  of  waste  or  accidental  products,  the  more  impor- 
tant ones  of  which  are  to  be  removed  and  saved  before  the 
factory  goes.  The  most  expensive  of  all  these  is  the  chloro- 
phyll. This,  with  starch,  sugars,  etc.,  is  to  be  carried  into  the 
body  of  the  plant.  But  they  are  not  transmissible  in  their 
present  form ;  they  must  be  changed  into  soluble  if  not  sim- 
pler substances,  and  so  removed  to  the  storage-places.     In 

318 


FORTY    YEARS    IN    TlfE    MEDICAL    PROFESSION 

this  breaking  up  of  the  chlorophyll  especially,  new  proflucts 
arise,  such  as  microsco])ic  oil-clrf)])S  and  certain  fine  granular 
bodies.  These  refract  the  light  and  arc  the  cause  of  the  color 
in  the  leaves,  together  with  other  coifM-ing-mattcrs  dissolved 
in  the  cell  sap.  In  a  word,  we  may  say  that  the  color  of  au- 
tumn foliage  is  due  to  waste  products  at  the  time  the  leaves 
are  being  emptied  of  valuable  material  preparatory  to  being 
cast  off  as  dead  tissue.  The  better  the  crop  of  leaves,  the 
more  brilliant  fall  colorings  we  may  expect.  Frost  is  not 
necessary  to  start  it,  only  chilly  nights.  The  changes  may 
occur  in  July  even,  if  wounds  or  disease  come  to  the  tree. 
In  the  northern  part  of  the  United  States  and  in  Canada  the 
colorings  are  brighter  than  in  the  Middle  States  or  farther 
south.  The  reason  is,  the  maple  abounds  in  the  North  and 
has  brilliant  coloring,  and,  moreover,  in  the  North  they  are 
not  subject  to  droughts  so  much  as  farther  south,  and  conse- 
quently the  cool  autumn  catches  the  leaves  with  richer  con- 
tents, more  color-forming  material. 

SPECIAL  FRUITS. 

The  Apple. — Chemically  the  apple  is  composed  of  vegeta- 
ble fibre,  albumin,  sugar,  gum,  chlorophyll,  malic  acid,  gallic 
acid,  lime,  and  much  water.  It  also  contains  more  prosphorus 
than  any  of  the  other  fruits  or  vegetables.  This  is  useful  in 
forming  the  nervous  matter  of  the  brain  and  spinal  cord  and 
the  general  nervous  system.  What  I  have  said  of  fruits  in 
general  will  apply  to  apples  and  all  fruits  to  follow,  and  I  wish 
merely  to  call  attention  to  the  best  of  the  species  for  all  pur- 
poses, and  especially  for  purposes  of  diet  for  the  sick.  A  phy- 
sician should  know  wdiich  apple,  which  pear,  which  grape, 
etc.,  is  the  best,  their  season,  and  all  about  them.  The  apple 
grows  in  most  of  the  States  of  the  Union,  and  is  generally 
distributed  over  the  world.  Some  varieties,  of  course,  are 
better  in  some  districts  than  others,  and  some  are  known  only 
in  certain  localities.  Of  the  hundreds  of  varieties  of  fruits.  I 
only  propose  to  mention  and  describe  those  which  have  merits 
sufiticient  to  warrant  them  a  place. 

319 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 
SUMMER    APPLES. 

SniJtincr  Queen. — This  is  the  best  of  our  early  summer 
apples  for  eating  out  of  hand  or  for  cooking.  It  is  striped 
with  red  on  a  yellow  ground,  and  is  of  medium  size,  some- 
what acid,  spicy  and  rich  flavor. 

Szveet  Bough. — Next  comes  the  Sweet  Bough,  a  greenish- 
yellow  apple,  sweet  and  pleasant  for  eating,  but  does  not  cook 
well. 

Red  Astrachaii. — Large,  striped,  red  apple,  very  beautiful, 
and  one  of  the  best  of  the  summer  apples  to  eat  raw  or  to 
cook.    It  came  to  us  from  Russia. 

Yellow  Transparent. — Also  a  Russian  apple,  of  a  light- 
yellow  color,  and  one  of  the  best  of  its  season. 

Summer  Permain. — One  of  the  very  best  and  handsomest 
of  the  late  summer  apples.  This  is  a  beautiful  red  apple  and 
very  choice  in  every  way. 

There  are  other  summer  apples,  but  they  are  not  much 
used  anyhow,  especially  now,  as  we  can  keep  over  the  winter 
varieties  so  late  by  cold  storage,  and  those  I  have  given  are 
the  best. 

FALL    APPLES. 

Maiden's  Blush. — This  is  the  handsomest  and  among  the 
best  of  the  early  fall  apples.  It  is  yellow,  with  a  distinct  blush, 
and  very  good  for  eating  and  cooking  and  for  decoration ;  it 
is  very  handsome. 

Fallawater  or  Tulpehocken. — This  is  a  large,  yellowish- 
green  apple,  and  very  good  for  eating  or  cooking. 

TJie  King  Apple. — This  is  a  large  red  apple,  and  in  every 
way  a  very  desirable  one. 

Smith's  Cider. — We  see  a  great  many  of  these  apples  in 
market  in  the  early  autumn.  It  is  a  red  apple,  very  good  to 
cook,  not  very  good  to  eat  raw. 

Grimes's  Golden  Pippin. — Yellow  with  russet  dots.  A  de- 
sirable fall  apple  in  every  way. 

Yellozv  Bell-Flozuer — Belle  Fleur. — Beyond  a  doubt,  when 
you  can  get  this  apple,  raised  in  Pennsylvania,  New  Jersey, 

320 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Delaware,  or  Maryland,  it  is  of  all  apples  facile  princeps  of  its 
own  season,  from  October  to  Christmas.  There  are  many  in 
the  market  coming'  from  the  West,  but  they  do  not  compare 
in  flavor  with  those  raised  in  the  States  mentioned.  The  sur- 
face is  pale  yellow,  with  a  beautiful  blush  in  the  better  speci- 
mens. The  apple  is  juicy  and  crisp,  with  a  spicy  aroma  and 
flavor  altog-ether  its  own. 

WINTER    APPLES. 

Baldzviii. — This  is  a  red  apple,  and  probably  the  most  com- 
mon apple  in  the  market  in  early  winter.  It  is  one  of  the 
best  of  the  all-round  apples,  being  tasty  and  pleasant,  both  to 
eat  out  of  hand  and  to  cook. 

Ben  Davis. — Of  late  this  is  the  apple  we  see  most  of  in  the 
winter  market,  especially  late  in  winter  and  in  the  spring.  It 
is  a  beautiful  red  apple,  but  there  its  good  traits  end.  It  is 
mealy,  soft,  and  tasteless,  and  has  not  one  redeeming  merit  to 
recommend  it,  except  its  looks  and  keeping  qualities.  The 
latter  especially  is  unfortunate,  for  the  sooner  it  rots  the  better 
for  lovers  of  good  fruit.  For  the  grower  it  is  unfortunately 
a  profitable  apple. 

Spitzcjihcrg. — This  is  a  solid,  not  very  attractive-looking 
red  apple,  known  among  the  market  men  as  "Spitz;"  but 
taste  it,  and  you  will  say  there  is  a  spiciness,  a  flavor,  that 
attracts  you ;  and  eat  another,  and  you  will  say,  "  Surely, 
this  is  the  best  apple  by  odds  I  have  ever  eaten."  It  is  the 
best  apple  /  have  ever  eaten.  No  other  apple  compares  with 
it,  not  even  the  Newtown  pippin  or  Bell-Flower.  It  is  very 
scarce  in  the  market.  New  York  is  the  chief  source  of  supply. 
There  the  trees  are  not  doing  well,  and  this  makes  the  apple 
scarce  and  high.  Never  mind  that;  buy  it  at  any  price  if 
you  w^ant  a  delicious  fruit  to  eat  out  of  hand  or  to  cook. 

Nezvtozvn  Pippin — Albemarle  Pippin. — This  is  a  grand 
apple,  and  the  best  specimens  grow  in  the  Shenandoah  Valley, 
in  Virginia,  and  its  neighborhood,  and  in  our  market  it  is  the 
most  expensive  apple,  bringing  nearly  double  the  price  of 
other  apples.  Her  ^Majesty  the  Queen  of  England  is  said 
21  321 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

to  import  a  supply  of  them  yearly,  although,  as  a  rule,  the 
Englishman  will  take  none  but  red  apples.  The  Newtown 
pippin  is  a  large,  yellowish-green  apple  when  ripe.  The  stalk 
is  short  and  deep-set,  and  surrounded  by  light-russet  rays. 
As  a  rule,  to  get  the  finer  specimens  now,  we  must  spray  the 
trees  with  fungicides,  as  we  must  all  apple-trees  at  the  present 
day. 

When  buying  apples  of  any  kind,  always  look  for  smooth, 
regular-shaped  specimens.  The  irregular  knotty  ones  have 
been  prey  to  insects.  Those  with  black  and  other  dark  spots 
have  been  prey  to  fungi,  and,  as  a  rule,  are  what  are  called 
scabby,  and  have  been  raised  by  careless  growers  and  are  not 
first  class. 

Rome  Beauty  is  an  apple  from  Ohio  we  see  frequently  in 
the  market.  It  is  of  medium  size,  verging  on  dark  red  in 
color,  and  is  in  every  way  desirable. 

Cart  House  and  its  seedling  Nero  are  lovely  apples;  in- 
deed, are  among  the  most  desirable  for  all  purposes.  There 
are  two  species  of  Cart  House, — the  yellow  and  the  white 
flesh.  The  skins  of  both  are  deep  red,  and  every  specimen 
will  without  an  exception  show  one  or  more  little  warty  ex- 
crescences. The  yellow-fleshed  variety  is  by  far  the  best, 
and  we  in  Delaware  never  take  any  other  when  we  have  the 
choice. 

Stayman's  Wine-Sap  (its  parent,  the  Old  Wine-Sap). — 
Always  buy  Stayman's.  This  species  originated  with  Dr. 
Stayman,  of  Kansas.  It  is  large,  of  a  bright-red  color,  keeps 
well,  and  is  in  all  respects  a  desirable  apple. 

Lady  Apple. — This  is  a  most  beautiful  little  apple  for  deco- 
rating purposes,  and  has  a  lovely  aroma  and  spicy,  attractive 
flavor.  It  is  of  a  yellowish  waxen  color,  with  deep  crimson 
cheeks  where  it  greets  the  rising  sun.  This  is  the  proper 
apple  to  treat  as  the  French  do  for  table  and  other  decora- 
tions. Just  before  the  coloring  sets  on  the  apple  they  apply 
with  an  adhesive  material  a  cut  of  any  figure  they  wish  to 
show  on  the  apple, — a  bird,  a  fish,  or  any  mythological  or 
other  figure.     This  remains  until  the  apple  is  gathered,  and 

322 


FORTY    YEARS    IN    TllIC    MI'.DICAL    PROFESSION 

if  still  adhering-,  it  is  removed  and  the  figure  shows  on  the 
apple.  In  Paris  apples  so  treated  bring  from  one  to  two 
francs  each. 

The  Morvcn  is  a  very  beautiful  apple  and  of  very  high 
flavor.  It  is  a  seedling  of  the  Lady  apple  but  somewhat  larger, 
and  originated  on  "  Morven,"  one  of  my  fruit-farms  at  New 
Castle,  Delaware. 

Northern  Spy. — This  is  a  large  red  apple,  with  much  green 
in  its  tinges,  and  is  one  of  the  first-class  fruits  found  in  our 
winter  market. 

There  are  several  native  Delaware  and  Eastern  Shore  of 
Maryland  apples  whose  cultivation  is  increasing.  If  you  ever 
come  across  them,  buy  them  and  you  will  not  regret  it.  They 
are:  Late  Delaware  Winter,  which  resembles  Lawver,  a  red 
apple;  Jackson,  a  red  apple  resembling  the  old  Grindstone, 
of  which  it  is  supposed  to  be  a  seedling;  Lankford,  a  red 
apple  w^ith  green  tinges ;   and  the  Lily  of  Kent. 

Smokehouse  is  a  red  apple,  a  very  good  one,  but  scarce 
after  November. 

Roxhury  Russet. — This  is  an  apple  of  beautiful  russet  color, 
of  medium  size,  and  shading  off  in  places  to  a  light  green  in 
many  specimens.  It  keeps  late,  and  is  a  most  toothsome  apple 
in  the  spring,  probably  the  best  obtainable  after  February. 
Golden  Russet  and  English  Russet  do  not  differ  greatly  from 
Roxbury  Russet.  Grindstone  is  a  good  apple  at  this  season 
also. 

Szvaar. — A  greenish  yellow.  If  you  can  buy  Swaar  you 
will  make  no  mistake,  especially  in  the  early  v^inter. 

York  Imperial. — A  light-crimson  apple,  shaded  with  dark; 
subacid  and  very  desirable. 

Stark. — You  will  often  find  Stark  in  the  market.  It  is  a 
greenish  yellow.    I  cannot  recommend  it  highly. 

Now  and  again  you  must  allow  an  apple  to  your  diabetic 
patients,  and  you  want  them  as  free  from  sugar  as  possible. 
The  best  for  such  a  purpose  are  Red  Astrachan,  Summer 
Permain.  Smith's  Cider,  Bell-Flower,  King,  Rome  Beauty, 
Spitzenberg  (this  is  the  apple  par  excellence  for  the  diabetic), 

323 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Northern  Spy,  Stark,  York  Imperial.  Apples  in  the  spring 
have  more  sugar,  and  should  then  be  avoided  by  the  diabetic. 
The  foregoing  list  comprises  the  best  obtainable,  and  is  suffi- 
cient to  suppl)^  apples  of  the  best  varieties  all  through  the 
apple  year.  Oregon  and  some  of  the  far  Western  States  are 
beginning  to  ship  us  apples.  They  come  in  boxes  like  ordi- 
nary orange-boxes  in  shape  and  holding  about  a  half-bushel 
of  fruit.  They  are  handsome,  but  are  by  no  means  equal  in 
flavor  to  the  apples  east  of  the  Rockies. 

Peaches. — The  chemical  composition  of  the  edible  parts 
of  the  peach  is  as  follows:  Water,  93.7;  protein,  .5;  fat,  .2; 
carbohydrate,  5.3;  ash,  .3.  Fuel  value  per  pound,  115.  I 
give  here  a  list  of  the  peaches  found  in  our  markets  during 
the  season,  and  as  nearly  as  possible  in  the  order  of  their 
ripening,  beginning  with  the  earliest,  which  usually  come 
from  Georgia,  beginning  the  latter  part  of  June,  and  ending 
with  those  coming  from- California  as  late  as  the  Christmas 
holidays. 

Alexander. — This  is  about  the  earliest  peach,  but  we  rarely 
see  it  except  when  it  is  grown  near  home,  as  it  is  too  delicate 
to  carry  far.  It  is  a  white  peach,  of  good  flavor,  and  usually 
a  freestone. 

Amsden. — This  closely  resembles  Alexander  in  every  way. 

Early  Rivers. — Freestone.  This  is  the  best  of  the  early 
peaches,  and  comes  ten  days  after  Alexander.  It  is  a  hand- 
some white  peach. 

Troth. — This  is  a  beautiful  little  white-flesh  peach  with 
deep  blush.  It  is  a  dry,  sweet,  mealy  peach,  and  is  a  free- 
stone. Some  years  peaches  cling  to  the  stone  more  than 
they  do  other  years.  Of  course,  there  are  some  peaches 
always  clingstone. 

Mountain  Rose. — Freestone,  white  flesh,  one  of  the  best 
peaches,  and  much  like  the  old  Early  York,  whose  place  it 
has  taken. 

St.  John. — The  best  large,  early,  yellow  peach,  with  a  red 
cheek. 

Foster. — A  very  good  orange-red  peach  with  yellow  flesh. 

324 


FORTY    YEARS    IN    THE    Ml'JJlCAL    PROFESSION 

Crawford's  Early. — This  is  much  like  T'oster,  but  it  is  not 
holding  its  own  as  a  variety;  it  is  freestone. 

Old  Mixon. — This  is  the  queen  of  peaches  as  to  flavor.  No 
other  peach  equals  a  perfect  Old  Mixon  in  flavor,  I  care  not 
where  it  is  grown;  and  those  grown  on  the  i^elaware  and 
Chesapeake  Peninsula  are  the  most  luscious  of  all  the  peaches 
of  the  world.  It  is  a  freestone.  The  skin  is  of  a  yellowish 
white  with  a  deep-red  cheek;  the  flesh  is  white,  red  at  the 
stone,  and  both  tender  and  rich. 

Moore's  Favorite. — Almost  exactly  like  Old  Mixon. 

Reeves's  Favorite. — A  very  large  and  handsome  peach  with 
yellow  flesh,  among  the  very  handsomest  and  best  of  the  yel- 
low peaches ;   freestone. 

Stump. — A  superb  peach  with  white  flesh  and  a  bright-red 
cheek,  and  is  free  from  the  stone. 

TJi'urber. — A  good  peach,  supposed  to  be  a  seedling  of  the 
Chinese  cling,  but  it  is  a  freestone. 

Old  Mixon  Cling. — Like  its  sister,  the  freestone  Old 
Mixon,  it  exceeds  in  flavor  all  other  cling  peaches,  but  is  a 
very  rare  peach  in  the  market. 

Mary's  Choice. — Resembles  Crawford's  Early,  but  is  su- 
perior to  it  in  every  way  as  found  to-day ;  freestone. 

Susquehanna. — A  rare  peach  in  the  market,  but  it  is  a 
magnificent  one  of  yellow  flesh  and  red  cheek,  and  is  usually 
very  large ;  freestone. 

Elhcrta. — A  truly  grand  peach,  and  the  show  peach  of 
Georgia.  It  is  a  seedling  of  the  Chinese  cling.  Yellow  flesh, 
with  beautiful  deep-red  cheek,  and  is  elliptical  in  shape  and 
freestone.  Its  only  fault  is,  some  specimens  have  some  bit- 
terness of  flavor. 

Georgia  Bell. — A  very  fine  peach,  something  like  Elberta. 
but  is  white  fleshed  and  comes  from  Georgia. 

Dr.  R.  P.  Harris  told  me  the  finest  peach  ever  in  the  United 
States  was  the  "  Robinson  Crusoe.''  a  seedling  grown  in  Dr. 
Cox's  yard  at  Ninth  and  Spruce  Streets.  Philadelphia.  Dr. 
Cox's  son  brought  the  stone  from  Juan  Fernandez  and 
planted  it. 

325 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

.  Crazi'ford's  Late. — A  superb  peach ;  yellow  flesh,  red  cheek ; 
very  large,  handsome,  and  luscious;  subacid  flavor;  free- 
stone. 

Lemon  Cling. — Elegant,  large,  and  handsome  cling  peach. 

Ward's  Late. — A  freestone,  white-flesh  peach,  with  a  beau- 
tiful red  cheek  and  delicious  flavor.    It  is  scarce  in  market. 

Chair's  Choice. — A  very  good  late  yellow-flesh  peach,  with 
red  cheek;   freestone. 

Fox's  Seedling. — One  of  the  best  of  the  late  white  free- 
stone peaches,  with  red  cheek.  It  is  rather  oval  in  shape,  with 
an  unguiform  projection  at  its  apex  end. 

Smock  and  Beer's  Smock. — Late,  yellow  flesh,  very  dry 
and  mealy  peaches,  much  used  in  canning  and  preserving. 
For  those  who  like  a  dry,  mealy  peach  they  are  very  fine. 

Doctor  Black. — A  very  late,  very  large,  lemon  flesh  color, 
luscious  freestone  peach.  The  finest  peach  of  its  time  of 
ripening,  coming  after  the  other  desirable  peaches  have  gone. 
Very  few  are  on  the  market,  but  Mr.  Charles  Wright,  of 
Seaford,  Delaware,  is  propagating  the  tree  commercially. 

Geary. — A  very  late  freestone,  yellow  peach,  which  has  the 
peach  flavor  somewhat,  but  never  ripens.  This  is  our  latest 
peach. 

White  Heath  Cling. — This  is  a  grand  peach,  is  very  scarce, 
and  is  the  proper  peach  to  brandy. 

Salway. — Not  very  good  in  the  East,  as  a  rule,  but  is  the 
best  peach  we  get  from  California,  and  can  be  bought  on  the 
fruit-stands  usually  up  to  Christmas.  It  is  mealy  as  we  get 
it,  and,  like  all  California  peaches  we  get  in  the  East,  is  in- 
sipid. The  other  peaches  coming  from  California  are,  chiefly, 
Early  and  Late  Crawfords. 

In  order  that  one  may  know  when  to  go  to  the  markets  for 
certain  peaches,  I  give  a  table  of  the  time  of  ripening  of  the 
better  varieties  of  the  Delaware  and  Chesapeake  fruits.  A 
week  to  ten  days  later  will  give  the  time  for  finding  the  New 
Jersey,  Western  Maryland,  and  Pennsylvania  peaches,  and 
four  to  six  weeks  earlier  will  find  the  same  varieties  from 
Georgia  and  the  South  and  Southwest:    Alexander,  July  i 

326 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

to  7;  Amsdcn,  July  i  to  7;  Early  Rivers,  July  20  to  25; 
Troth,  Au^c^ust  15  to  20;  Mountain  Rose,  August  23;  Fos- 
ter, August  15  to  18;  Crawford's  Early,  August  15  to  20; 
Reeves,  August  20;  Moore's  Favorite,  August  23;  Old 
Mixon,  August  25 ;  Ward's  Late  Free,  September  i  to  2 ; 
Sus(iuchanna,  August  31;  Mary's  Choice,  August  20; 
Stump,  September  i;  Crawford's  Late,  August  30;  Fox's 
Seedling,  September  5  to  7;  Smock  and  Beer's  Smock,  Sep- 
tember 15;  Salway,  yellow,  freestone,  September  25;  White 
Heath  Cling,  for  brandied  peaches,  October  i  to  15;  Doctor 
Black,  October  10  to  15;   Bilyeu,  October  i  to  12. 

If  a  diabetic  should  eat  peaches  at  all,  and  he  surely  may 
now  and  again,  the  proper  ones  for  him  are  the  subacid  varie- 
ties, the  best  of  which  are  Foster,  Early  and  Late  Crawford, 
Reeves,  Susquehanna,  Smock,  Salway,  Elberta,  Doctor  Black, 
and  Bilyeu.  I  look  upon  the  peach  particularly,  but  all  fruits 
more  or  less,  as  very  important  articles  of  diet.  The  acids 
of  the  peach  are  very  prone  to  break  up  the  compounds  of  the 
waste  substances,  particularly  of  nitrogenous  waste,  and  thus 
they  are  enabled  to  pass  off  through  the  kidneys,  and  an  ex- 
cess of  water  drunk  helps  this  passing  off.  These  tissue- 
wastes  may  be  largely  in  the  form  of  uric  acid,  and  thus 
peaches  particularly  may  help  sufferers  from  rheumatism, 
gout,  and  allied  disorders,  by  breaking  up  these  compounds 
and  placing  them  in  a  condition  to  be  eliminated  from  the 
system,  and  thus  relieving  the  toxaemia,  for  toxaemia  it 
really  is. 

Pears. — These  I  give  in  the  order  of  their  ripening.  The 
summer  pears  are  usually  perishable,  but  the  late  pears  hold, 
many  of  them,  up  to  Christmas,  and  by  the  use  of  cold  storage 
can  be  held  indefinitely,  and  are  found  in  our  markets  up  to 
warm  weather  in  the  spring.  I  may  say  here  that  pears  are 
grown  on  the  natural  grafted  or  budded  pear-tree, — that  is, 
pear  on  pear, — but  many  are  grown  on  quince  stock.  This 
dwarfs  the  tree,  and  hence  we  have  standard  pears  and  dwarf 
pears.  The  dwarf  trees  are  shorter  lived,  but  undoubtedly 
produce  the  best  specimens  of  fruit  in  every  wa3^    Some  varie- 

327 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

ties  dwarf  better  than  others.  Some  pear-trees  require  to 
be  double  worked  to  get  good  results;  that  is  to  say,  you 
graft  one  variety  on  a  stock,  and  then  next  year  to  this  you 
graft  a  variety  that  grows  well  only  on  this  last  stock.  There 
are  half -standard  trees,  that  is  to  say,  trees  that  have  been 
planted  as  dwarfs, — pears  on  quince-roots, — and  these  planted 
deep  enough  to  throw  out  roots  from  the  pear  stock  as  well 
as  from  the  quince.  These  trees  live  longer  than  pure  dwarf 
trees.  Early  pears  ripen  better  in  a  cool  room  or  shaded  spot, 
after  they  have  been  picked.  Late  pears  should  be  left  on  the 
trees  as  long  as  possible,  then  kept  as  nearly  as  possible  in  a 
temperature  of  40°  F.,  and  then  moved  to  a  warmer  apart- 
ment as  we  wish  to  ripen  them.  Wilder  and  Koonce  are  two 
early  pears,  whose  status  is  not  yet  exactly  known.  Man- 
ning's Elizabeth  is  the  best  of  our  early  summer  pears  for 
eating  out  of  hand,  and  is  due  in  mid-summer.  Its  flesh  is 
melting,  sweet,  and  perfumed,  with  plenty  of  juice.  It  is 
rather  a  small  red  pear,  with  some  russet  on  the  crown  half. 

Lazvson. — One  of  the  most  beautiful  pears  grown,  but  not 
of  high  quality  to  eat.  It  comes  in  July.  It  very  much  re- 
sembles the  German  pear,  Forelle,  the  most  highly  colored  of 
all  pears  when  properly  grown.  The  only  place  I  have  ever 
seen  the  Forelle  in  market  in  this  country  was  in  Baltimore. 
These  pears,  the  Lawson  and  Forelle,  are  very  valuable  for 
decorative  purposes,  and  for  the  sick-room  are  equal  to  the 
rose,  violet,  or  carnation;  and  what  is  more  comforting  to 
the  sick  than  fruit  and  flowers  and  the  subdued  tones  of  sweet 
music,  and  what  a  touching  object-lesson  has  Dumas  given 
us  in  "  La  Dame  aux  Camelias" ! 

Bartlett. — Among  the  grandest  of  pears  in  every  point  of 
view.  The  best  come  from  Pennsylvania,  New  York,  Dela- 
ware, and  Maryland,  the  handsomest  from  California,  but 
these  lack  flavor.  When  will  people  learn  to  buy  fruit  for 
eating  purposes,  not  by  its  color,  but  by  its  taste?  A  dealer 
in  choice  fruits  some  time  ago  asked  me  if  I  had  any  highly 
colored  pears  to  send  him;  he  said  it  made  no  difference 
about  flavor,  he  wanted  high  color,  to  make  it  sell.     Califor- 

328 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

nia  sends  the  clearest,  cleanest,  highest  colored  fruits,  be- 
cause her  climate  is  so  dry  and  free  from  fungi,  which  do 
so  much  to  harmlessly  discolor  fruit.  Jt  all  lacks  flavor  here, 
for  it  is  pulled  too  green.  In  California  it  is  better,  but  not 
equal  to  Eastern  fruit. 

Clapp's  Favorite  is  a  handsome  i)car,  but  a[)t  to  be  found 
unsound  at  the  core. 

Doyenne  d'Ete  is  a  small  summer  pear,  as  its  name  indi- 
cates ;  of  good  flavor. 

Buifum  is  a  very  nice  russet  pear  coming  in  the  early  au- 
tumn. 

DucJiesse  d'Angoidcuic. — One  of  the  largest  and  grandest 
of  pears,  and  w^hen  properly  ripened  is  superb  for  eating.  It 
has  a  thick  skin  and  not  always  high  color,  but  these  do  not 
hurt  it.  No  one  should  eat  the  skin  of  any  fruit;  the  rind 
carries  germs,  pathogenic  and  otherwise,  in  abundance.  If 
you  cannot  pare  the  fruit,  at  least  wash  it  thoroughly. 

Anjon. — One  of  the  very  best  of  pears,  and  comes  to  us 
late  in  the  season ;  and  from  California  it  comes  late  into  the 
winter  and  spring.  The  Anjou  is  one  of  the  great  pears,  and 
you  will  make  no  mistake  in  buying  them  when  able. 

Clairgcau. — A  beautiful  pear,  but  not  often  found  in  our 
market,  except  from  California ;  nor  is  Flemish  Beauty. 

Hozuell. — This  is  a  lovely  pear,  much  like  the  Bartlett.  It 
is  the  whitest  in  flesh  of  all  pears,  and  this  makes  it  a  beau- 
tiful pear  to  seal  in  glass. 

Seckel. — We  all  know  Seckel.  that  lovely  little  pear  which 
comes  to  us  in  the  early  autumn,  and  is  only  excelled  in  flavor 
by  one  pear,  and  that  pear  is  Dana's  Hovey.  This  looks 
something  like  Seckel,  with  some  cinnamon  russet  on  it.  It 
is  melting,  buttery,  juicy,  with  a  honeyed  sweetness  and  ex- 
quisite aroma.  It  is  undoubtedly  the  highest  flavored  of  all 
pears.  Seckel  is  second  to  it.  Dana's  Hovey  comes  very 
late.  We  ought  to  find  it  in  the  market  in  November,  De- 
cember, and  January.  I  think  it  is  more  easily  obtained  in 
Washington  and  Boston  than  in  other  places. 

Lazvroice. — I  want  to  recommend  the  Lawrence  pear.     It 

329 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

is  a  lovely  pear,  and  few  are  better  for  eating  or  packing". 
Its  merits  are  not  generally  known.  It  is  not  a  showy  pear, 
and  seldom  has  any  color  except  yellow  and  green.  You 
might  sell  to  the  passing  crowd  one  barrel  of  the  beautifully 
colored  California  Bartletts  while  you  were  selling  a  handful 
of  Lawrence.  The  handful  of  Lawrence,  however,  is  worth 
the  barrel  of  Bartletts  for  eating  purposes. 

Bosc. — A  long,  slim,  russet  pear,  so  good  a  pear  that  some 
pronounce  it  not  excelled  b}^  any  pear  that  grows. 

Sheldon. — A  large,  yellow,  russet  pear,  nearly  of  the  aver- 
age apple  shape.  If  the  Sheldon  pear  should  be  offered  you, 
buy  it ;  you  will  seldom  get  a  better  one. 

Kieffer. — The  modern  wonder  among  pears.  It  is  a  hy- 
brid, and  supposed  to  come  from  the  union  of  the  Japanese 
sand  pear  and  the  Bartlett,  and  was  found  growing  in  a  gar- 
den in  the  city  of  Philadelphia.  It  is  a  most  wonderful  pear 
to  produce  fruit,  and  will  keep  to  mid-winter  or  later,  if  prop- 
erly cared  for,  without  cold  storage,  and,  if  well  ripened,  has 
a  fair  flavor  and  a  beautiful  blush  for  decorative  purposes. 
It  is  a  great  winter  pear,  and  many  barrels  are  yearly  sent  to 
Europe.  Next  to  the  Bartlett  and  Howell,  it  is  the  best  pear 
to  can.  It  is  white  and  clear,  but  if  too  much  sugar  is  added 
it  takes  on  a  pink  tinge.  This  does  not  hurt  it  at  all,  but 
dealers  object  to  it  as  off  color.  It  is  probably  the  most 
profitable  pear  to  raise  in  the  East;  at  least  my  own  experi- 
ence tells  me  so,  as  I  have  hundreds  of  trees  on  my  fruit 
farms.  The  proper  way  to  handle  it  is  to  allow  it  to  remain 
on  the  tree  as  long  as  possible,  then  gather  it  and  lay  in  long 
rows  under  the  trees  in  the  orchard,  and  only  remove  to  the 
house  when  freezing  weather  threatens.  Keep  them  at  about 
40°  F.  until  you  want  to  ripen  them  up,  when  a  warmer  tem- 
perature soon  makes  them  fit  to  eat  or  to  can.  They  are  bet- 
ter canned  when  ripe  and  not  too  green.  To  ship  them  to 
Europe  they  usually  reduce  the  temperature  by  a  month's 
cold  storage  before  starting  them. 

The  pears  that  come  to  us  from  California  are  the  Clair- 
geau,  the  Easter,  the  Bartlett,  the  Winter  Nelis,  the  Anjou, 

330 


FORTY    YEARS    IN    TJIK    MEDICAL    I'KOFESSION 

and  the  Doyenne  du  Corniclie.  They  are  all  fairly  good,  but 
the  best  is  Winter  Nelis,  so  far  as  I  am  able  to  judge.  As 
to  pears  in  general,  they  are  among  the  best  and  most  luscious 
of  our  fruits,  and  to  pick  out  the  best  is  a  difficult  under- 
taking. In  my  opinion,  the  three  highest  flavored  pears  are 
the  Dana's  Hovey,  the  Seckel,  and  the  Bosc,  in  the  order  here 
given.  For  an  invalid,  such  as  a  diabetic,  the  Kieffer  is  the 
best  for  him,  and  may  be  allowed  now  and  again.  The  chemi- 
cal composition  of  the  pear  is  as  follows:  Water,  83.9;  pro- 
tein, .6;  fat,  .8;  carbohydrates,  14.2;  ash,  .5.  Fuel  value 
per  pound,  310.  Recollect  this  is  an  analysis  of  the  edible 
portion  only.  Pears  are  stronger  food  than  peaches,  but  not 
so  strong  as  apples. 

Grapes. — The  chemical  composition  of  grapes  is  as  fol- 
lows:  Edible  portion,  water,  78.8;  protein,  1.3;  fat,  1.7; 
carbohydrates,  17.7;  ash,  .5.  Fuel  value  per  pound,  425. 
Probably  a  little  stronger  than  apples.  The  best  grapes 
grown  in  the  East,  for  eating  purposes,  are  as  follows : 

Moore's  Early. — This  is  the  best  of  the  early  grapes.  It  is 
a  large  black  grape  with  a  blue  bloom. 

Warden. — A  fine  grape,  and  as  an  eating  grape  is  superior 
to  Concord,  and  has  a  thin  skin  and  a  large  berry. 

Concord. — A  large  purplish-black  grape.  It  comprises  a 
large  portion  of  the  grapes  we  see  on  sale  in  the  market.  It 
has  not  a  very  high  flavor,  but  is  useful  for  all  purposes  that 
grapes  are  put  to. 

Delazvare. — A  small  red  grape,  and  probably  the  best  fla- 
vored of  all  the  grapes  we  buy  of  the  American  type. 

Catazvha. — Next  to  the  Delaware  in  flavor  is  the  Catawba. 
It  is  a  larger  grape,  and  is  a  very  common  one  in  the  market. 

Martha. — A  white  grape,  and  one  of  very  high  flavor. 

Lady  is  about  as  good  as  IMartha,  and  is  white. 

Niagara  is  the  white  grape  we  see  most  of  in  the  general 
market.  It  is  a  very  good  grape,  with  a  little  of  the  fox}' 
flavor. 

Empire  State  is  a  grape  much  like  the  Niagara,  but  possi- 
bly not  quite  so  good. 

331 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Pockliiigtoii  is  another  white  grape,  and  probably  has  a 
better -flavor  than  either  Niagara  or  Empire  State. 

Clint 0)1  is  the  great  wine  grape  for  domestic  wine,  and 
Salem  is  another,  but  the  juice  of  any  of  them  makes  a  fair 
wine.  For  unfermented  grape-juice,  the  Concord  is  most 
used,  because  it  is  plentiful  and  cheap. 

The  before-mentioned  grapes  are  all  of  the  American  va- 
riety and  are  distinguished  from  the  European  varieties  by 
the  fact  that  the  skins  are  thick,  the  pulp  holds  the  seeds  inter- 
woven with  it,  and  the  pulp  comes  out  of  the  skins  holding 
the  seeds,  and  when  eaten  we  usually  swallow  seeds  and  pulp 
and  discard  only  the  skin.  In  the  European  varieties  of 
grapes  the  seeds  are  merely  set  in  the  pulp  unattached,  and 
can  be  picked  out  like  the  kernels  of  a  nut,  and  we  eat  skin 
and  pulp,  discarding  only  the  seeds.  Most  of  the  California 
grapes  we  get  in  the  market  are  of  the  European  variety,  and 
far  excel  any  we  can  raise  in  the  open  air  east  of  the  Rocky 
Mountains. 

Tokay. — This  is  the  beautiful  large  red  grape  we  see  so 
many  of  in  baskets  holding  from  five  to  eight  pounds.  It 
is  an  elegant  grape,  of  delicious  flavor  and  aroma,  and  is 
more  eaten  here  than  any  of  the  Pacific  coast  grapes. 

Muscat. — This  is  by  far  the  highest  flavored  of  the  Cali- 
fornia grapes  we  get  in  the  East.  It  is  a  white  grape,  with 
the  true  Muscat  flavor  and  aroma,  and  is  a  revelation  to 
grape-eaters.  The  Muscatelle  is  a  smaller  grape  of  the  same 
flavor  as  the  Muscat. 

Emperor. — This  is  a  red  grape  from  California,  but  not  so 
often  seen  as  the  before-mentioned  varieties. 

Morocco. — This  is  a  black,  round  grape,  and,  like  all  the 
grapes  from  the  Pacific  coast,  is  attractive  and  pleasant. 

Ferdel  is  a  white  grape  which  has  been  mentioned  to  me, 
but  I  am  not  familiar  with  it. 

Cornichon  is  a  black  grape,  large,  egg-shaped,  and  quite 
plenty  in  the  market,  especially  late  in  the  season.  It  has 
good  flavor,  but  is  the  most  unsatisfactory  of  the  California 
grapes,  as  it  is  of  the  American  type,  where  the  pulp  and 

332 


FORTY    YEARS    IN    Till-:    MEDICAL    PROFESSION 

seeds  intcrniinL;ic  or  tangle  up;  the  skin  is  thick,  and  un- 
pleasant if  eaten. 

Raisins. — The  CaHfornia  raisins  are  pro1)ably  now  the  best 
in  the  world.  The  cHmate  is  most  suitable,  and  the  grapes 
from  which  they  are  made  are  in  every  way  satisfactory. 

Coleman  Grape. — This  is  the  great  black  grape,  with  stems 
half  an  inch  in  diameter,  which  we  see  in  the  fancy  fruit- 
stores,  the  bunches  weighing  pounds,  and  selling  for  fabulous 
prices.  These  grapes  are  imported  from  Englanfl,  where 
they  are  grown  under  glass  as  one  of  the  luxuries. 

The  English  and  French  fruits,  including  peaches,  plums, 
apricots,  and  such,  grown  under  glass  or  protected  in  some 
way,  are  magnificent;  they  are  perishable,  and  of  course  we 
never  see  them  here ;  even  there  they  are  only  luxuries  those 
in  affluent  circumstances  can  enjoy.  We  grow  here  under 
glass  very  fine  grapes  of  the  European  type  which  are  of 
exquisite  flavor  and  full  aroma.  Among  the  best  are  Black 
Hamburg,  a  very  large  black  grape;  Sw^eet  Water,  a  white 
grape  of  good  flavor;  and  the  Muscat,  always  fragrant  and 
always  acceptable  to  sick  or  well.  The  white  Almeria  grapes 
come  to  us  from  Spain,  on  the  borders  of  the  Mediterranean, 
and,  although  rather  insipid,  fill  a  void  when  no  other  grape 
is  in  the  market. 

Apricots. — The  apricot  is  a  delicious  fruit,  coming  as  it 
does  very  early  in  the  season,  between  cherries  and  peaches, 
and  from  California  we  get  them  quite  early  in  the  spring. 
The  California  apricots  hold  the  Eastern  market  because  so 
few  are  raised  here  owing  to  the  attacks  of  the  curculio  and 
worms  at  the  collar  of  the  tree.  These  are  matters  now  wdiich 
we  know  all  about,  and  the  remedies  are  at  hand,  and  it  is 
the  fault  of  the  grower  in  omitting  attention  to  details  if  he 
does  not  succeed  in  raising  apricots  as  well  in  the  East  as  they 
do  in  California.  The  Russian  varieties  do  best  with  us, 
probably,  and  the  best  of  these  is  Harris  Hardy,  with  a  flavor 
exceeding  any  of  those  brought  from  the  Pacific  coast. 
Others  we  grow  in  the  East  are  Early  Golden,  Acme,  Moor- 
park,  and  Roman.     Gibbs  is  an  extra  early,  ripening  in  June, 

333 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

and  Budd  is  a  late  one  of  good  quality.  Apricots  are  raised 
on  peach  stocks,  on  almond  stocks,  on  apricot  stocks,  and  on 
Myrobolan  plum  stocks.  Among  the  best  of  the  California 
apricots  are  the  New  Castle,  Russian,  Moorpark,  Blenheim, 
and  Royal.  There  are  many  other  varieties.  The  apricot  is 
naturally  more  nearly  allied  to  the  plum  than  to  the  peach, 
having  the  broad  leaf  and  the  smooth  stone  of  the  plum,  but 
having  down  on  its  skin  like  the  peach. 

Nectarines. — On  the  other  hand,  the  nectarine  is  a 
peach,  with  a  smooth  glossy  skin  like  the  plum.  The  nec- 
tarine is  inferior  in  every  way  to  the  peach  and  to  the  apricot 
as  a  fruit.  It  has  more  of  the  noyau  flavor  than  has  the  peach. 
Among  the  good  varieties  are  the  Downton,  Boston,  New 
White,  Old  White,  Lord  Napier,  Elruge,  and  Golden. 

Plums. — The  plum  is  a  popular  fruit,  and  we  may  look 
for  a  great  increase  in  its  cultivation  in  the  East  and  a 
great  increase  in  the  fruit  in  the  markets.  They  have  been 
arranged  in  two  divisions, — Division  I.,  red,  purple,  blue; 
Division  II.,  green,  white,  yellow.  There  are  varieties  of 
plums  without  end.  J.  W.  Kerr,  of  Denton,  Caroline  County, 
Maryland,  is  one  of  the  great  American  authorities  on  plums. 
He  is  a  large  nurseryman  and  propagator  of  these  and  other 
trees,  and  a  large  plum-grower  for  market.  In  his  American 
group,  native  plums,  he  gives  over  one  hundred  and  twenty- 
five  varieties,  among  the  names  being  American  Eagle,  Cali- 
fornia, Etta  Holt,  Kieth,  Louisa  Smith,  Stella,  Winnebago, 
Yellow  Sweet,  Sloe.  We  will  begin  to  find  a  constantly  in- 
creasing supply  of  native  plums  in  our  markets,  and  they  are 
bound  to  become  an  important  part  of  the  fruit  supply  for  the 
masses.  The  Nigra  group  is  for  the  far-off  cold  Northwest, 
and  we  will  probably  see  few  of  them  here,  but  they  will  give 
those  people  a  hardy  fruit  for  their  inhospitable  climate.  The 
Miner  group  of  plums  are  grown  in  the  East  and  are  late  in 
ripening.  The  Wayland  group  are  hardy,  and  grow  in  all 
parts  of  the  country  except  the  extreme  Northwest.  The 
Wild  Goose  group  is  the  profitable  group  for  the  country 
south  of  New  York  in  the  East,  and  Wisconsin  in  the  West, 

334 


FORTY    YEARS    IN    'JJII-:    MEDICAL    PROFESSION 

and  are  the  ones  we  are  most  a])t  to  encounter  in  the  markets 
of  New  York,  Philadelphia,  Baltimore,  anrl  Washington. 
Among  the  hest  varieties  are  Choptank,  Clifford,  Freeman, 
Kroh,  Ohio,  Osage,  Smiley,  Sophie  Whitaker,  Red  Cling, 
Wild  Goose,  Wooten.  The  Chickasaw  group  of  native  plums 
is  for  the  country  south  of  Mason  and  Dixon's  line.  Among 
the  best  are  Munson,  Newman,  Piram,  and  Yellow  Trans- 
parent. 

Besides  the  l)efore-mentioned  groups  of  native  plums,  we 
have  the  Watsoni  group,  the  Marianna  group,  the  Maritima 
group,  the  Primus  bcsseyi  (the  sand  cherry),  the  mongrels, 
and  others,  not  yet  classified.  Truly,  a  great  class  of  fruits, 
and  one  destined  to  do  great  good  as  it  goes  on  in  its  evolu- 
tion to  perfect  types. 

The  next  type  of  plums  is  the  Triflora  group,  or  the  Japan 
plums.  Much  of  this  fruit  comes  to  us  now  from  Califor- 
nia, and  the  beautiful  large  plums  we  see  in  the  fruit-stores 
are  mostly  from  this  source.  Delaware  and  Maryland  are 
growing  them  now  in  perfection,  and  our  supply  of  the  future 
will  be  much  of  it  from  these  States.  The  Abundance  is  the 
variety  we  see  most  of, — large,  oblong,  mottled,  lemon-yellow, 
sometimes  much  red,  cling.  Another  is  Berckman's,  a  cling, 
and  another,  Burbank,  which  rots  badly.  Hale  is  a  good  one, 
greenish  yellow,  with  streaks  and  shadings  of  red,  cling.  Kel- 
se}^,  greenish  yellow  with  red,  or  all  red.  Kerr,  very  early, 
cling,  conical,  bright  yellow.  Red  June,  very  early  and  good. 
White  Kelsey,  large,  conical,  greenish  white.  Yosebe,  ear- 
liest of  all  Japan  plums,  small,  red,  freestone.  Chabot.  one 
of  the  best,  red  on  yellow  ground,  cling. 

I  give  here  the  chemical  analysis  of  the  average  apricots, 
nectarines,  plums,  and  prunes.  Plums,  edible  portion  :  Water, 
78.4;  protein,  i ;  carbohydrates,  20.1 ;  ash,  .5.  Fresh  prunes, 
edible  portion:  Water,  80.2;  protein.  .8;  carbohydrates,  18.5; 
ash,  .5.  Dried  prunes,  edible  portion:  Water,  26.4;  protein, 
2.4;  fat,  .8;  carbohydrates,  68.9;  ash,  1.5.  Nectarines,  edi- 
ble portion:  Water,  82.9;  protein,  .6;  carbohydrates,  15.9; 
ash,  .6.     Apricots,  edible  portion:  Water,  85;  protein,   i.i; 

335 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

carbohydrates,  13.4;  ash,  .5.  Fuel  value  per  pound  of  plums, 
390;  of  fresh  prunes,  360;  of  dried  prunes,  1360;  of  necta- 
rines, 305 ;  of  apricots,  270. 

Many  of  the  old  plums  under  the  old  names  may  still  be 
found  in  market,  and  among  the  best  are  the  Lombard,  the 
red  gage,  Smith's  Orleans,  Washington,  green  gage.  Impe- 
rial gage.  Damson,  and  others. 

Fresh  Prunes. — If  we  get  fresh  prunes  here  in  the  East, 
they  probably  come  from  California.  Prunes  are  plums,  that 
is  the  long  and  the  short  of  it.  A  fresh  prune  is  a  plum  of  a 
variety  which,  when  dried  in  a  peculiar  way,  makes  the  dried 
prunes,  or  prunes  of  our  market.  The  names  of  the  chief 
varieties  of  the  French  prune  plums  are  the  St.  Catharine  and 
the  Brignolles,  with  a  number  of  others.  The  chief  Califor- 
nia varieties  are  the  Brignolles,  Bulgarian,  Datte  de  Hongrie, 
German  Golden,  Hungarian,  Silver,  St.  Catherine,  St.  Mar- 
tin's, Tragedy,  Wangenheim,  Giant,  and  Imperiale  Epineuse. 
The  fruit  is  picked  after  the  dew  is  dried  off.  California  has 
an  advantage  here  over  France, — the  climate  is  so  dry.  The 
fruit  is  then  ripened  in  shallow  baskets.  When  ripe  it  is  shut 
up  in  spent  ovens  for  twenty-four  hours.  It  is  then  removed 
and  the  ovens  reheated.  Then  the  prunes  are  replaced  in  the 
ovens.  In  twenty-four  hours  they  are  again  removed,  turned 
over,  and  laid  on  the  leaves  in  the  bottoms  of  the  baskets.  A 
third  time  the  ovens  are  heated  and  the  prunes  are  returned, 
and  in  twenty-four  hours  are  taken  out  and  allowed  to  cool. 
They  are  again  heated  from  one  to  three  times  more,  and 
then  they  are  packed  and  ready  for  market.  Nearly  all  of 
the  prune  output  of  California  is  sun-dried,  and  no  artificial 
heat  is  required.  There  is  a  plum  there  called  the  Hungarian 
prune,  yellow  egg,  much  of  which  is  cured  by  heat  in  evapo- 
rators. There  is  a  large  prune  product  in  Oregon,  Washing- 
ton, and  Idaho,  nearly  all  of  which  is  cured  by  artificial  heat 
in  evaporators. 

The  prunellos  are  plums,  sometimes  called  prunelles.  They 
are  dried  and  packed  in  regular  masses  like  dates,  and  come 
in  boxes  or  mats.     They  are  quite  acid,  and  not  very  easily 

336 


FORTY    YI'ARS    JN    TllJi    AIKDICAL    PROFESSION 

digested.  Remember,  always,  in  Ijuying  plums  of  any  kind 
fresh,  to  see  that  they  are  just  ripe  and  not  over-ripe.  After 
fermentations  of  decay  have  started  in  them  they  become 
very  hospitable  hosts  for  many  germs,  pathogenic  and  other- 
wise, and  are  apt  to  produce  what  the  boys  call  "  green-apple 
bellyache,"  or  something  worse. 

Date  Pliiiii. — Some  species  of  this  tree  produce  ebony,  and 
are  valuable  trees.  They  are  of  the  genus  Diospyros,  belong- 
ing to  the  natural  order  Ebcnacecc.  The  chief  species  from 
which  the  fruit  comes  is  the  Diospyros  kaki,  or  Chinese  date 
plum.  Our  common  persimmon  is  of  this  genus,  the  Dios- 
pyros virginiana,  and  is  quite  a  good  fruit  after  it  has  been 
well  frosted  and  developed  its  sugar.  We  are  all  familiar 
with  dates,  how  they  come  in  mats.  They  have  a  good  flavor, 
and  are  a  useful  fruit  for  many  purposes.  The  Diospyros 
kaki  gives  us  the  Japanese  persimmon.  We  see  them  in  mar- 
ket now,  fresh  from  California  and  near  by.  Few  of  them 
thrive  in  the  open  air  in  the  East  above  the  Carolinas.  Fine 
ones  come  from  Florida.  The  Tane  Nashi  is  a  yellow  seed- 
less one,  and  thrives  in  the  open  air  on  the  lower  part  of  the 
Delaware  and  Chesapeake  peninsula. 

The  chemical  composition  of  dates  and  persimmons  is  as 
follows:  Edible  portion,  water,  20.8;  protein,  2.2;  fat,  5.1; 
carbohydrates,  70.4;   ash,  1.5.     Fuel  value  per  pound,  1565. 

Tamarinds  come  to  us  chiefly  from  the  West  Indies.  The 
tamarind-tree  also  grows  in  the  East  Indies.  I  never  thought 
much  of  tamarinds.  They  are  said  to  be  laxative  and  cool- 
ing. The  tree  furnishing  the  fruit  is  the  Tamarindus  indica. 
The  fruit  is  a  pod  from  two  to  six  inches  long,  containing 
seeds  or  beans,  with  a  pulp  something  like  our  common  locust 
bean.  The  pulp,  put  up  with  sugar,  gives  us  tamarinds  as  we 
get  it. 

The  mango,  of  the  species  j\[augifera,  we  get  green,  as 
a  pickle,  or  put  up  with  sugar  as  a  preserve;  neither  is  of 
much  account.  The  mangosteen  we  never  see  in  the  United 
States,  but  will  probably  see  them  frequently  when  we  run 
over  to  Manila  to  shake  hands  with  our  fellow-citizens  of  the 
22  3Z7 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Philippines.  When  those  islands  become  States  of  the  Union, 
we  may  get  them  from  there  in  cold  storage.  \Vhen  we  do 
get  them,  and  get  them  in  prime  condition,  they  will  be  of 
about  the  shape  and  size  of  an  orange,  and  have  a  broad,  pel- 
tate, lobed  stigma.  The  rind  is  like  that  of  the  pomegranate ; 
it  is  also  something  like  the  pomegranate  in  structure.  It  is 
at  first  green,  and  changes  to  dark  brown.  It  is  said  to  be 
the  most  luscious  of  fruits,  the  pulp  and  juice  a  mingling  of 
the  strawberry  and  grape.  It  is  absolutely  healthy,  and  can 
be  eaten  with  safety  in  the  tropics  in  great  quantities  by  sick 
or  well. 

The  Durian. — Here  is  another  East  Indian  fruit.  The 
expansionists  probably  had  eaten  it,  and  know  what  they  are 
going  for.  It  is  a  most  delicious  fruit,  which  undoubtedly 
those  of  our  people  who  oppose  expansion  to  the  East  have  not 
yet  tasted.  The  name  of  the  tree  bearing  the  fruit  is  the  Durio, 
of  the  family  Sterculiaceco,  the  only  known  species  of  its  genus, 
Durio  zibethinus.  The  fruit  is  round  or  oval  and  nearly  a 
foot  long.  It  has  a  hard  rind,  with  prickles.  It  has  five  cells, 
each  with  several  seeds.  The  pulp  is  of  a  light  yellow,  with  a 
delicious  flavor,  and  an  odor  not  at  all  inviting.  The  seeds 
are  cooked  and  eaten  like  nuts. 

The  papaw  is  the  fruit  of  the  Carica  papaya.  It  is  some- 
thing like  a  fig,  and  is  eaten  like  it.  The  taste  grows  on  one. 
It  is  coming  into  use  as  a  digester  of  albuminoids.  I  have 
the  trees  growing,  having  raised  them  from  the  seed.  They 
grow  wild  in  Delaware,  especially  around  mill-ponds,  but  are 
difficult  to  transplant.  In  the  southwestern  part  of  the  United 
States  they  grow  wild  luxuriantly. 

Pomegranate. — The  many-seeded  fruit,  botanically.  The 
tree  bearing  this  fruit  is  Punica  granatum.  There  are  two 
kinds,  the  sweet  and  the  sour,  of  a  yellow  color  tinged  with 
red.  The  pulp  is  the  edible  portion.  It  is  hardy,  even  in  the 
Middle  States,  if  trained  on  the  southern  side  of  walls  or 
other  protector.  I  have  eaten  them  in  California  and  Mexico, 
where  they  thrive  admirably.  They  are  a  poor  fruit  where 
we  have  so  many  better  ones,  but  may  be  grateful  in  hot 

338 


FORTY    YKAKS    IN    TIHC    MICDICAL    PROFESSION 

weather  to  one  craving  acid.  The  l)ark  contains  much  tannin, 
and  is  used  mech'cinally  where  an  astrinj:^cnt  is  neerlcd. 

Figs. — Tlie  fruit  of  tlie  Ficus  carica.  Chemical  analysis: 
Water,  79.1;  protein,  1.5;  carbohydrates,  18.8;  ash,  .6. 
Fuel  value  per  pound,  380.  Figs  thrive  in  the  c^pen  air,  on 
the  lower  part  of  the  Delaware  and  Chesapeake  Peninsula, 
and  from  there  south  and  on  the  Pacific  coast.  The  fresh 
fig  is  very  sweet,  to  some  insipid,  and  to  others  very  grateful. 
Great  quantities  of  them  can  be  eaten  at  once  when  just  ripe, 
as  they  are  very  digestible.  They  are  cured  by  artificial  heat, 
and  in  California  in  the  open  air.  They  have  a  reputation 
as  an  aperient;  this  is  probably  on  account  of  the  peristalsis 
produced  by  the  physical  action  of  the  seeds. 

GuAVA. — From  the  fruit  of  the  Psidium  guaiava.  The 
fruit  is  bright  yellow,  and  very  fragrant;  indeed,  so  fra- 
grant is  it  that  the  taste  appears  insipid  after  the  delightful 
odor.  It  comes  to  us  chiefly  from  the  West  Indies  and  Flor- 
ida.   The  jelly  made  from  it  is  delightful. 

Alligator  Pear  (Persea  Gratissima) . — This  fruit  is  a 
native  of  the  West  Indies  and  of  tropical  America.  The 
leaves  and  the  bark  have  some  reputation  as  an  antiperiodic. 
I  have  eaten  them  on  the  western  coast  of  Mexico,  where 
they  are  highly  esteemed  as  a  breakfast  course. 

Alligator  Apple. — Fruit  of  the  West  Indian  tree, 
Anona  palustris.  I  give  it  here  merely  to  distinguish  it  from 
the  alligator  pear.  It  is  used  medicinally  as  an  astringent 
chiefly  in  Mexico.     It  is  known  as  the  Custard  Apple. 

The  Cocoanut. — Fruit  of  the  Cocos  nucifcra,  one  of  the 
best  known  of  the  palm-trees,  and  which  always  greets  us  as 
we  approach  the  shore  of  any  of  the  tropical  islands.  It 
flourishes  only  near  the  sea,  but  will  grow  inland  in  hot 
countries,  but  is  unfruitful  there.  The  blossoms  are  very 
beautiful.  The  clusters  of  blossoms  are  produced  every  six 
weeks  during  the  wet  season,  and  each  cluster  produces  a 
number  of  nuts.  In  planting  nuts,  the  three  black  spots,  or 
monkey  eves,  are  set  upward,  and  from  one  of  these  eyes  the 
stem  emerges.     In  the  tropics  the  trees  live  one  hundred 

339 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

years;  in  greenhouses,  from  ten  to  twelve  years  only.  In 
the  tropics  the  wood  is  known  as  porcupine  wood.  Here 
the  large  leaves  are  used  for  clothing  and  to  build  huts.  They 
are  also  used  for  writing  on  and  for  fans,  fences,  nets,  sieves, 
combs,  etc.  Of  the  husks,  scrubbing-brushes,  ropes,  and  such 
utensils  are  made.  The  juice  extracted  from  the  flowers 
makes  a  drink.  Fermented,  it  makes  palm  wine;  distilled, 
it  yields  arrack,  like  that  obtained  from  rice.  The  nuts  when 
green  contain  quite  a  quantity  of  fluid.  This  is  much  used  as 
a  cooling  drink,  and  the  gelatinous  mass  lining  the  shells  is 
eaten  alone  or  flavored  to  suit  the  taste.  If  too  much  of  the 
juice  is  taken,  it  irritates  the  urinary  organs.  It  contains 
sugar,  water,  gum,  oils,  and  soluble  and  insoluble  salts.  What 
we  know  as  cocoa-nut  is  the  albumin,  etc.,  deposited  on  the 
inside  of  the  shell.  It  is  dried  and  prepared  as  we  see  it  in 
the  market,  and  used  for  various  purposes  by  both  the  sick 
and  the  well.  The  chemical  analysis  is  as  follows :  Water, 
3.5;  protein,  6.3;  fat,  57.4;  carbohydrates,  31.5;  ash,  1.3. 
Fuel  value  per  pound,  3125.  Quite  a  strong  combination, 
truly.  There  is  much  oil  extracted  from  the  cocoa-nut,  which 
makes  the  finest  soaps,  candles,  and  such,  and  for  body  lubri- 
cation it  is  unsurpassed.  The  cocoa-nut  is  a  digester  of  albu- 
moses,  and  an  active  one,  from  a  proteolytic  ferment  which 
it  contains. 

Banana. — A  plant  of  the  genus  Musa.  The  banana  is 
Mitsa  sapientiim,  the  plantain  is  Musa  paradisiaca.  We  buy 
in  our  markets  bananas  for  plantains,  and  we  buy  plantains 
for  bananas.  For  food  there  is  not  much  difference.  They 
come  yellow  and  red.  The  red  are  usually  larger.  The 
chemical  analysis  of  each  is  about  as  follows:  Water,  74.1; 
protein,  1.2;  fat,  .8;  carbohydrates,  22.9;  ash,  i.  Fuel 
value  per  pound,  480.  Compare  this  with  boiled  white 
potatoes,  and  see  how  nearly  they  approach.  The  potato 
has  most  of  its  carbohydrates  in  starch,  and  the  banana  in 
sugar  and  starch.  The  sweet  potato  has  both  sugar  and 
starch.  Boiled  white  potato:  Water,  y^^.y;  protein,  2.7; 
fat,  .2;   carbohydrates,  22.3;   ash,  i.i.     Boiled  sweet  potato: 

340 


FORTY    YJ':ARS    in    TIJI-:    MEDICAL    PROFESSION 

Water,  69.3;  protein,  1.8;   fat,  7;  carbohydrates,  27.1 ;  ash, 
I.I.     Fuel  vahie  per  pound:  White  potatoes,  475;  sweet  po- 
tatoes, 565.     Here  we  read  the  vahies  as  food  of  the  three 
great  staples, — the  banana,  the  white  potato,  and  the  sweet 
potato.    The  banana  grows  from  the  slip;  that  is  to  say,  they 
cut  the  plant  off  at  the  ground  and  transplant  it.     I  have  seen 
them  l)rought  from  the  West  India  Islands  and  planted  in 
Florida  in  this  way,  and  they  thrive  in  the  southern  part.    The 
fruit  is  very  green  when  cut  to  ship  to  our  Northern  cities, 
and  suffers  in  flavor  compared  to  that  cut  and  ripened  in  the 
tropics.     Formerly  much  was  lost  in  shipping,  but  now  fast 
steamers  bring  it  in  three  or  four  days  from  Jamaica,  Cuba, 
and  the  nearer  islands,  and  we  are  getting  the  fruit  in  good 
shape  compared  with  the  earlier  days.     Fifty  years  ago  a 
banana  was  almost  a  curiosity  in  Philadelphia;    now  it  is  a 
staple  article  of  diet,  and  a  very  wholesome  one.     In  the 
tropics  the  banana  is  the  eating  variety,   and  the  plantain 
usually  the  variety  they  cook  in  various  ways.     They  are 
fried,  baked,  and  made  into  pies  and  puddings.      Bananas 
are  dressed  with  wine,  with  sugar  and  cream,  and  with  wine 
and  orange  and  other  juices.     I  think  the  devil  is  the  author 
of  some  of  these  mixtures,  by  which  he  hopes  to  inveigle 
some  foolish  mortals  he  has  set  his  keen  eyes  upon.     The 
natives  cut  bananas  into  strips  and  dry  them,  and  mash  this 
up  and  eat  it.    We  are  getting  now  into  our  markets  a  banana- 
meal.    This,  I  think,  will  prove  a  good  thing  for  both  sick  and 
well.     It  may  be  eaten  in  any  way  after  cooking,  as  we  eat 
porridge  of  any  kind ;   with  milk  or  cream  and  a  little  sugar 
added,  it  is  most  palatable  and  invigorating.     In  eating  the 
banana  out  of  hand,  it  should  be  very  ripe,  and  it  is  not  very 
ripe  until  the  skin  has  softened  and  turned  well  black.     Fer- 
mentation has  not  commenced  on  the  inside  when  the  skin 
is  quite  dark. 

The  Pine-Apple. — This  is  another  of  the  tropical  fruits 
rapid  transit  is  putting  in  our  markets  in  prime  condition.  In 
the  parlance  of  trade  they  are  called  *'  Pines."  It  takes  its 
name  from  its  resemblance  to  the  pine-cone.     Botanically  it 

341 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

is  Aiiaiiassa  sativa.     It  belongs  to  the  family  BronicUacccE. 
From  this  its  active  principle,  bromelin,  takes  its  name.     We 
formerly  looked  upon  pine-apple  as  a  most  unwholesome  fruit 
in  every  way,  as  a  breeder  of  all  sorts  of  diseases,  especially 
of  cholera.     How  little  we  knew  then  of  the  origin  of  such 
troubles,  and  the  merits  and  demerits  of  things  to  be  eaten! 
If  prepared  properly,  pine-apple  is  a  most  digestible  fruit, 
and  is  a  digester  itself  of  albuminoids,  from  the  ferment  bro- 
melin  it  contains,  as  before  spoken  of.     The  wrong  way  to 
eat  pine-apple  is  to  shred  it  and  throw  away  the  core  and  the 
skin,  for  in  the  core  and  fibre  and  skin  resides  the  bromelin. 
The  proper  way  to  eat  pine-apple  is  to  shred  it  and  then 
squeeze  all  the  juice  out  of  the  fibre  and  core  and  skin,  spread 
it  over  the  pine-apple,  and  eat  it  thus,  plain  or  sweetened,  and 
after  eating — not  before  eating — other  things.     The  proper 
time  to  eat  pine-apple  is  after  dinner,  or  after  a  "  dejeuner  a 
la  fourchette."    Then  the  bromelin  assists  the  digestion  of  all 
the  albuminoids  consumed  at  the  meal.     So  powerful  is  this 
bromelin  that  if  persons  eat  the  skin,  the  core,  or  the  fibre, 
particularly,  the  tender  skin  and  mucous  membrane  of  the 
lips  and  tongue  and  inside  of  the  mouth  goes  through  a 
process  of  digestion  in  spots,  and  pine-apple  sore  mouth  is 
developed.     Here  is  a  scientific  explanation  of  what  every 
one  knows  comes  now  and  again  from  eating  pine-apple.    The 
best  preventive  is  to  cleanse  the  mouth  and  lips  with  water, 
or  better,  mint  water,  or  some  of  the  essential-oil  waters, 
after  having  eaten  this  fruit.     I  frequently  prescribe,  with 
very  good  results,  pine-apple  juice  for  the  dyspepsia  arising 
from  the  indigestion  of  the  nitrogenous  foods.     This  juice, 
to  be  effective,  should  be  made  from  the  fresh  fruit,  using 
the  skin,  core,  fibre,  and  all,  and  then  straining  it.     A  wine- 
glassful  or  more  may  be  taken  after  eating.     If  you  cannot 
get  the  fresh  juice,  you  may  use  the  juice  of  the  shops,  with 
more  or  less  effect,  but  the  fresh  juice  is  the  best,  as  it  is  of 
all  fruits  for  all  purposes.     The  best  and  finest  pine-apples  I 
ever  saw  were  grown  on  the  island  of  Toboga,  in  Panama 
Bay.     The  chemical  analysis  of  the  pine-apple,  edible  por- 

342 


FORTY    YKAKS    IN    THE    MEIJICAL    PROFESSION 

tion,  is  as  follows:  Water.  '^9.3  ;  ])rotein,  .4;  fal,  .3;  car- 
bohydrates, 9.7;   asli,  .3.     i'"uel  value  i)ei'  ])oiiiul,  200. 

The  Orangic. — The  (|ueen  of  the  citrus  fruits,  Citrus  au- 
rantium  and  other  varieties.  The  other  citrus  fruits  are  the 
lime,  the  lemon,  the  citron,  the  bergamot,  and  the  shaddock. 
The  orange  needs  a  favorable  soil  and  climate.  In  Europe 
the  orange  grows  as  far  north  as  42°.  It  will  not  do  it  in 
our  country  east  of  the  Rocky  Mountains.  They  grow  the 
best  in  the  world  in  Florida ;  they  are  also  grown  in  Louisiana 
and  Mississii:)pi,  and  a  few  in  Texas,  Georgia,  and  Alabama, 
In  Arizona  they  grow  to  perfection,  and  in  California  they 
are  a  staple  crop,  being  chiefly  of  the  seedless  navel,  so  called; 
they  are  a  Bahia  orange.  Our  Consul  there  found  that  they 
grew  wild  in  the  surrounding  jungles.  He  sent  a  few  cut- 
tings to  the  Agricultural  Department  at  Washington,  and  Mr. 
Saunders  succeeded  in  growing  a  few  of  them,  and  gave  a 
few  to  Mrs.  Luther  C.  Tibbetts,  of  California,  who  took  them 
to  her  husband,  Luther  C.  Tibbetts,  at  Riverside,  California. 
He  succeeded  with  them,  and  to  him  is  due  the  honor  of  in- 
troducing the  navel  orange  from  Bahia,  Brazil,  into  Cali- 
fornia. 

The  orange  is  a  native  of  India,  and  grows  wild  along  the 
southern  slopes  of  the  Himalaya  Mountains  among  the  tribu- 
taries of  the  Ganges.  They  were  brought  to  the  United 
States  from  Europe.  The  seedling  orange-tree  is  known  to 
exist  over  six  hundred  years  old.  The  seedling  trees  live 
much  better  and  longer  than  the  grafted  trees ;  in  fact,  graft- 
ing is  a  devitalizing  process  as  far  as  the  orange  goes,  if  it 
does  not  apply  to  all  grafted  trees.  The  grafted  orange-trees 
give  us  better  fruit  and  commence  to  bear  earlier,  but  their 
limit  of  useful  life  is  about  twenty-live  years.  The  chemical 
analysis  of  the  orange  is  as  follows:  Water,  88.3:  protein, 
.8;  fat.  .6;  carbohydrates,  9.7;  ash,  .6.  Fuel  value  per 
pound,  220. 

Real!}'  the  best  oranges  I  ever  tasted  I  bought  in  Acapulco, 
on  the  western  coast  of  Mexico.  They  were  a  very  small 
yellow  orange,  grown  on  the  mountain-slopes,  and  were  prob- 

343 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

ably  seedlings,  as  the  Mexicans  did  not  give  much  care  to 
improying  the  natural  character  of  their  fruits.  The  sweet 
orange  is  the  Citrus  aurantiuui,  as  before  stated.  The  bitter 
orange  is  the  Citrus  vulgaris.  We  have  no  use  for  it  except 
for  its  bitter  peel  now  and  then,  and  to  send  it  to  the  Scotch- 
man with  which  to  flavor  his  Dundee  jam  or  marmalade.  We 
all  know  of  the  uses  of  orange-blossoms  for  their  lovely  per- 
fume, for  the  adornment  of  the  bride  where  they  are  classic, 
and  for  the  making  of  orange-flower  water.  In  the  orange 
countries  we  see  the  blossoms  on  the  tree  and  the  fruit  of  the 
last  season  still  hanging,  truly  an  enchanting  scene,  and  the 
melting  odors  from  the  bloom  render  the  surroundings  ravisse- 
ment.  The  best  oranges  we  get,  as  I  have  said  before,  come 
from  Florida.  The  Indian  Rivers  are  the  best  of  these.  They 
also  send  us  some  very  fine  navels.  The  special  oranges  are 
the  Mandarins  and  the  Tangerines,  the  Chinese  types,  those 
little  oranges  which  slip  from  their  skins  like  walnuts  from 
their  hulls,  and  in  doing  so  do  not  soil  your  kid  glove;  they 
have  a  flavor  and  odor  of  their  own,  and  to  some  they  are  very 
palatable.  There  is  another  little  curiosity  of  the  Citrus  type, 
the  cute  little  Comquot,  or  Chinese  orange.  They  are  a  con- 
densation of  lusciousness  and  full  of  aroma.  You  eat  them 
skin  and  all,  and  to  the  sick  and  weary  invalid  they  are  often 
a  revelation,  and- help  his  lagging  digestion.  They  come  to 
us  from  Florida.  Jamaica  sends  us  good  oranges,  and  mani- 
fest destiny,  it  appears,  will  soon  literally  smother  us  with 
such  luxuries  from  our  new  colonial  possessions. 

Shaddock. — The  fruit  of  the  Citrus  decumana,  the  word 
decumana  referring  to  its  size, — immense.  It  is  supposed  to 
be  the  "  forbidden  fruit,"  and  was  introduced  into  the  West 
Indies  from  China  by  an  English  sea-captain.  Shaddock  by 
name.  It  comes  to  us  now  from  the  West  Indies  and  Florida 
chiefly  as  grape  fruit.  The  quality  of  the  fruit  is  inferior: 
it  is  at  once  sour,  bitter,  and  unpleasant,  but  has  become  pop- 
ular to  eat  before  breakfast  as  a  peristaltic  persuader,  and  is 
also  used  at  ladies'  luncheons,  but  is  here  dressed  with  sugar 
and  sherry  and  other  wines,  to  make  it  palatable.    The  devil, 

344 


FORTY  YEARS  IN  THE  MI':DICAL  PROFESSION 

I  am  sure,  Ii.'ul  something  to  flo  willi  llic  invention  of  this  last 
concoction,  and  women  are  still  nsin^  it  to  lemjjt  their  own 
sex,  if  not  to  tempt  man. 

Olivks. — The  fruit  of  the  Olca  ciirofxvd,  or  common  olive. 
The  lilac  and  the  ash,  among  our  well-known  trees,  come 
under  the  same  order  as  the  olive.  They  furnish  us  with 
olive  oil  and  the  fruit.  The  oil  we  are  all  familiar  with,  or, 
rather,  we  suppose  we  are,  but  much  of  what  we  get  in  the 
shops  for  pure  olive  oil  is  expressed  from  cotton  seed  and 
peanuts,  both  of  which,  by  the  way,  when  properly  handled, 
make  fair  table  oils.  True  olive  oil,  as  we  find  it  in  Italy, 
would  not  suit  our  tastes  in  America  at  all.  It  is  dark  and 
heavy,  with  strong  taste  and  odor  peculiarly  its  own.  It  is 
remarkable  how  one  gets  accustomed  to  it  and  comes  to  like 
it.  It  is  like  leaving  France  and  her  sweet  saltless  butter  and 
going  to  England  and  eating  her  salted  butter.  At  first  the 
difference  is  marked,  but  we  soon  become  accustomed  to  it. 
The  oil  is  gotten  from  the  fruit  by  expression,  and  as  fine  as 
I  ever  tasted  was  at  the  home  of  my  late  friend,  Tiburcio 
Parrott,  in  the  Napa  Valley,  California.  He  paid  great  atten- 
tion to  the  getting  of  a  good  quality  of  oil,  and  California 
and  her  olive  interests  lost  a  good  and  progressive  helper 
when  he  died.  For  eating,  the  olive  goes  through  a  prepara- 
tion peculiarly  its  own,  to  get  it  rid  of  its  bitterness  and  un- 
pleasant flavor.  The  fruit  is  gathered  green,  but  full  grown, 
varying  in  size  from  a  filbert  to  a  pigeon's  egg,  and  is  then 
put  into  strong  h^e,  and  after  a  while  in  water,  which  is  re- 
newed often  for  several  days.  They  are  then  bottled  and  a 
liquor  poured  over  them  one-half  water  and  one-half  satu- 
rated brine,  with  a  number  of  aromatics  added,  this  brine 
being  first  boiled.  We  find  ripe  olives,  with  the  stones  re- 
moved, treated  in  the  same  way.  They  are  far  the  best  for 
eating,  I  think,  and  add  zest  to  the  post-prandial  wine  and 
nuts.  The  olive  farcie  is  a  toothsome  but  rich  morsel.  They 
are  the  piece  de  resistance  of  olives,  and  are  made  by  extract- 
ing the  stone  and  stuffing  with  anchovy,  etc. 

Lemons. — The  fruit  of  the  Citrus  limonium.  and  one  I 

345 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

almost  overlooked,  yet  one  of  the  most  important  and  grate- 
ful medicinally.  Its  juice,  its  rind,  and  its  oil  are  equally 
useful.  It  came  originally  from  India  with  the  orange.  The 
lemon-  and  orange-trees  are  much  alike  and  grown  under  the 
same  conditions  of  soil  and  climate.  Lemon- juice  contains 
two  per  cent,  of  citric  acid,  with  mucilage  and  a  bitter  ex- 
tractive. There  is  one  peculiarity  about  the  oil,  as  about  most 
of  the  essential  oils, — it  does  not  keep  long,  but  becomes  to 
all  intents  and  purposes  turpentine  and  utterly  unfit  for  its 
special  uses.  We  should  insist  always  on  having  such  oils 
fresh  or  properly  preserved  from  this  change.  Mixing  with 
alcohol  is  the  proper  way  to  preserve  them. 

The  Mulberry. — The  red  mulberry.  Morns  rubra,  is  a 
common  one,  and  one  of  the  best,  having  a  pleasant,  very 
sweet  flavor.  Being  very  perishable,  it  is  only  found  in  the 
market  a  short  time.  The  same  may  be  said  of  the  white  and 
the  black  mulberry.  They  are  closely  related  to  the  fig  fam- 
ily of  fruits.  The  white  mulberry,  the  Morns  alba  multicau- 
lis,  is  the  favorite  tree  for  the  silkworms  to  feed  upon,  and 
doubtless  most  of  us  remember  the  stories  of  our  grandfathers 
of  the  excitement  produced  by  the  silkworm  craze  years  ago. 
Downing's  Ever-Bearing  is  probably  the  best  producer  of  the 
best  berries,  and  goes  on  producing  day  after  day  during  a 
long  season.  Few  ever  appear  in  the  market.  They  are  a 
healthy  fruit. 

The  Cantaloupe. — The  best  and  most  delicate  fruit  of 
the  melon  tribe,  and  so  named  from  the  Villa  Canteluppi^ 
near  Rome,  where  the  fruit  abounds.  It  comes  from  the  Cii- 
curbitacece,  or  gourd  family,  and  is  botanically  the  Cucuniis 
melo.  It  grows  almost  anywhere  in  America.  The  best 
come  from  Delaware,  Maryland,  New  Jersey,  and  Colorado. 
The  skin  is  roughened  with  a  cork-like  net-work,  and  the 
better  the  specimen  the  more  developed  is  this  net-work.  The 
small  round  or  oval,  dark  greenish-yellow  specimens  are  the 
best,  although  some  of  the  large  elliptic-shaped  ones  are  of 
good  flavor.  There  is  a  mean-looking  melon  of  small  size, 
with  the  net-work  well  developed,  with  dark-green  coloring, 

346 


FORTY    YEARS    JN    THE    MEDICAL    PROFESSION 

and  a  snout  at  one  cxlrcniily,  usually  of  a  lighter  color, 
on  the  order  of  a  wart.  This  melon  usually  comes  from 
Gloucester  and  Salem  Counties,  in  New  Jersey.  It  is  with- 
out doubt  the  best  and  most  luscious  of  all  specimens  yet  in- 
troduced, possibly  barrinfj^  the  new  melon,  Kocky  Ford,  from 
Colorado.  Look  at  it  (jnly,  and  ycni  would  ]jass  it  by  as  for 
the  pigs;  taste  it,  and  you  will  never  cease  to  praise  it.  Jenny 
Lind  is  its  name.  The  market  men  call  them  "  Ginnys."  Just 
as  I  am  writing  this  I  received  the  following  note  with  seeds 
from  my  friend,  Dr.  Robert  P.  Harris,  of  Philadelphia : 

"  I  send  you  a  new  citron  melon  from  Greece.  There  were 
four  kinds  of  seeds,  and  their  testing  in  Florida  showed  that 
these  were  the  best,  produced  the  largest  citrons  and  the  most 
distinctive.  Fruit  yellow  fieshed,  ten  by  thirteen  inches,  semi- 
translucent,  superior  to  known  varieties.  Try  them.  They 
are  in  the  shape  of  a  truncated  cone,  as  to  form  of  melon."  I 
zuill  try  them,  and  the  "  Harris,"  I  have  no  doubt,  will  excel. 
A  few  days  after  I  received  the  seeds  Dr.  Harris  died,  and  all 
good  work  lost  a  devoted  follower. 

The  Watermelon. — The  delight  of  our  fellow-citizens 
of  African  descent  and  the  pride  of  the  small  boy.  Botani- 
cally,  the  Citndlus  vulgaris.  It  grows  almost  anywdiere  and 
under  almost  any  conditions.  Thousands  come  to  our  mar- 
kets yearly,  starting  in  June  or  earlier  from  Florida,  and 
ending  with  those  from  New  Jersey  up  to  the  appearance  of 
the  Frost  King  in  September.  They  are  of  various  colors 
externally,  the  Southern  melons  being  generally  striped  with 
light  and  dark  green  lengthwise,  with  the  forbidding  name 
of  rattlesnake.  Thoroughly  chilled  with  ice,  they  are  a  lus- 
cious delicac}'-  on  hot  days,  are  very  healthy,  somewhat  diu- 
retic, and  altogether  desirable  for  the  well,  and  often  for  the 
sick.  The  seeds  are  without  doubt  valuable  in  some  cases  as  a 
diuretic. 

The  chemical  composition  of  the  cantaloupe  is  as  follows : 
Edible  portion,  water,  89.5;  protein,  .6;  carbohydrates,  9.3; 
ash,  .6.  Fuel  value  per  pound,  185.  That  of  the  watermelon 
is  as  follows :    Edible  portion,  water,  92.9 ;   protein,  .3 ;    fat, 

347 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

.i;  carbohydrates,  6.5;  ash,  .2.  Fuel  value  per  pound,  130. 
There  is  a  citron  melon,  a  true  watermelon.  It  is  spherical 
and  marked  with  stripes  and  shades  of  green.  It  is  hard  and 
tough,  and  is  used  only  for  preserves.  It  makes  a  handsome, 
clean  preserve,  and  so  does  the  rind  of  the  edible  watermelon. 
Its  chemical  composition,  dried  and  sugared,  is  as  follows : 
Water,  25.6;  protein,  .4;  fat,  .6;  carbohydrates,  72.5;  ash,  .9. 
Fuel  value  per  pound,  1380.  The  carbohvdrates  here  are 
doubtless  mostly  sugar. 

Partridge  Berry. — Here  we  have  a  very  interesting  berry 
for  the  physician,  often  called  the  teaberry,  the  flavor  of  which 
is  familiar  to  every  child  in  his  candy-stick.  Botanically  it 
is  Gaultheria  procumbens,  and  I  believe  is  the  same  as  the 
Mitchella  repens  of  Gray,  which  is  also  called  checkerberry, 
winter  clover,  and  w4ntergreen.  It  is  a  beautiful  little  red 
berry,  of  a  sprightly  pungent,  aromatic  taste,  in  market 
throughout  the  winter.  Its  flowers  are  very  fragrant.  It  is 
an  evergreen  trailing  plant,  creeping  around  the  roots  of  trees 
in  moist  places  in  the  woods  and  swamps.  The  fruit  is  often 
grateful  to  invalids,  and  especially  is  useful  in  lithsemic  cases. 
This  berry  is  one  of  the  sources  of  oil  of  wintergreen,  and 
much  of  it  is  prepared  in  New  Jersey  according  to  the  United 
States  Dispensatory.  Professor  Proctor  has  also  obtained 
it  from  the  sweet  birch.  It  is  supposed  to  exist  in  the  roots 
of  Poly  gala  paucifolia  and  in  the  roots  and  stems  of  Spircoa 
ulmaria,  Spircua  lohata,  and  Gaultheria  hispidula.  This  is  all 
of  great  importance  to  the  physician  on  account  of  the  free 
use  now^  made  of  salicylic  acid  and  its  salts,  especially  in  the 
treatment  of  rheumatism  and  gout.  The  question  here  arises. 
Is  there  any  advantage  arising  from  the  use  of  it,  as  it  exists 
in  nature  in  these  plants,  over  that  produced  synthetically  by 
chemical  process?  This  is  done  by  the  method  of  Kolbe,  by 
treating  a  solution  of  carbolic  acid  in  caustic  soda  with  car- 
bon dioxide  at  a  moderate  heat.  Horatio  Wood  lays  down 
the  chemical  difference  very  clearly.  Thus,  oil  of  winter- 
green  contains  ninety  per  cent,  of  methyl  salicylate,  a  substi- 
tution compound  in  which  one  atom  of  the  hydrogen  of  sali- 

348 


FORTY    YiiARS    IN    'I'lll-:    MI-:i)]CAI.    J'KOl'ICSSION 

cylic  acid  has  been  replaced  hy  a  molecule  of  melhyl,  Cll..,. 
The  formula  of  salicylic  acid  is  CtHoO.-j.  The  formula  of 
methyl  salicylate  is  Cj  (  ^jj^'j  j  O.,.     VVhen  oil  of  wintergreen 

is  taken  into  the  animal  system,  one  atom  of  carbon  anrl  two 
atoms  of  hydrogen  in  the  methyl  are  removed  by  oxidation 

and  C^  (  q^^  j  O.j  becomes  CyHnO.}.     C7  (  ^f^  )  O3  has  an 

atomic  weight  of  152,  while  the  atomic  weight  of  C^HuOg  is 
138.  The  administration  of  one  hundred  and  fifty-two  grains 
of  methyl  salicylate  ought  to  be  equivalent  to  the  administra- 
tion of  one  hundred  and  thirty-eight  grains  of  salicylic  acid. 
Now,  as  one  hundred  and  sixty-nine  grains  of  oil  of  gaul- 
theria  contain  one  hundred  and  fifty-two  grains  of  methyl 
salicylate,  they  should  be  equivalent  to  one  hundred  and 
thirty-eight  grains  of  salicylic  acid.  Now,  the  important 
question  comes  up.  Does  the  use  of  the  natural  salicylic  acid 
in  these  different  vegetable  sources,  as  from  the  partridge 
berry,  birch,  and  such,  have  any  advantage  over  the  use  of  the 
synthetic  compound  made  artificially  by  using  carbolic  acid, 
caustic  soda,  and  carbonic  acid?  Stokvis  has  investigated 
the  subject  closely,  according  to  Horatio  Wood,  and  concludes 
that  there  is  a  marked  quantitative  difference,  the  natural 
acid  being  distinctly  less  poisonous  than  the  synthetic  product. 
This  he  believes  to  be  due  to  the  superior  osmotic  action  of 
the  natural  acid.  There  is  a  general  impression  abroad  that 
the  artificial  product  is  much  more  irritating  to  the  kidneys 
than  the  natural,  and  therefore  it  is,  I  think,  better  to  use 
the  oil  of  wintergreen  as  our  source  of  salic3dic  acid  than  to 
use  the  artificial  salicylate  or  its  salts,  as  the  sodium  salicy- 
late; although  I  am  not  inclined  to  believe  one  much  more 
injurious  than  the  other,  especially  if  we  use  the  salt  and  not 
the  pure  acid,  which  I  believe  is  now  rarely  done.  I  am 
particularly  well  pleased  with  the  combination  of  colchicine 
and  methyl  salicylate  in  acute  gout.  I  have  given  this  par- 
ticular notice  to  the  partridge  berry  to  show  what  great  im- 
portance in  medicine  may  attach  to  an  insignificant  little 
fruit,  and  to  impress  upon  my  readers  the  importance  of  accu- 

349 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

rate  investigation  into  such  now  universally  used  remedies  as 
salicylic  acid  and  its  salts,  and  methyl  salicylate  as  it  exists 
in  nature. 

Pigeon  Berry  or  Poke  Berry. — The  beautiful  lake-col- 
ored berry  of  the  common  poke,  Phytolacca  decandra,  should 
receive  mention  here,  if  merely  to  warn  persons  that  it  is  not 
free  from  danger  if  used  as  food,  and  has  some  of  the  prop- 
erties ascribed  to  it  as  a  cure  for  rheumatism.  Pigeons  are 
very  fond  of  the  berries,  and  when  eating  them  abundantly 
their  flesh  may  be  poisonous,  as  pheasants  may  be  from  eating 
the  laurel.  Poke-root  is  emetic.  Another  poke  is  the  Indian 
poke  growing  wild  around  us.  This  is  the  American  helle- 
bore, and  produces  the  well-known  remedy,  formerly  used 
more  than  at  present,  Veratrmn  viride.  White  hellebore  is 
the  European  hellebore,  the  Veratriim  album. 

Haw. — The  hawberry,  or  at  least  one  of  them,  of  a  dark- 
blue  color  when  ripe,  is  a  very  toothsome  one,  but  the  species 
which  bears  it  is  a  very  rare  one;  indeed,  I  am  in  doubt  as 
to  its  identity  and  whether  it  comes  under  the  hawthorns  or 
the  stone  fruits.  The  buckthorns,  as  a  rule,  have  purgative 
qualities,  and  we  get  the  valuable  cascara  sagrada  from  the 
California  buckthorn,  the  Rhainnus  piirshiana. 

Wine  Berry. — A  new  berry  of  the  raspberry  order,  and 
said  to  be  different  from  any  other  berry.  It  is  juicy,  and  its 
flavor  is  sweet,  and  may  be  used  for  eating,  wine,  preserving, 
or  canning. 

Logan  Berry. — Another  new  berry  among  the  fruit  men. 
It  grows  or  trails  on  the  ground  like  the  dewberry.  Its  fruit 
is  often  over  an  inch  long,  dark  red  in  color,  with  the  shape 
of  a  blackberry  and  the  color  of  a  red  raspberry,  with  a  com- 
bination of  the  flavor  of  both. 

Gooseberries. — The  gooseberry  is  a  very  common  fruit, 
and  with  cultivation  and  proper  ripening  it  is  very  toothsome, 
especially  the  large  English  varieties  introduced  here.  These 
are  at  the  same  time  very  delicate,  from  the  tendency  of  the 
berries  to  mildew  {erysiphe  mors  uvcc).  It  comes  botanically 
under  the  type  Rihes  grossiilaria.    There  are  many  species  in 

350 


FORTY    yjOARS    IN    'II ll',    MI'.DICAL    PROFESSION 

America.  'Hicy  niak'c  .'imonj^-  the  Iiest  of  jams,  and  analyze 
as  follows:  Refuse,  3.5;  water,  85.7;  protein,  .5;  carbo- 
hydrates, 9.8,  which  includes  1.4  per  cent,  acid;   ash,  .4. 

The  Currant. — There  are  two  species  of  the  Rihcs  tribe. 
The  Rihcs  rubrum,  the  red  currant,  is  the  one  we  generally 
see  in  this  country,  and  the  best  varieties  are  the  Red  Dutch 
and  Fay.  The  fruit  is  (juite  acid,  yet  a  few  of  them  are 
pleasant  to  eat,  and  are  healthy.  There  are  also  some  white 
varieties,  or,  rather,  some  light-colored  varieties.  The  black 
currant  is  the  one  most  used  in  England,  and  has  a  heavy 
odor  and  flavor  of  its  own.  The  red  currant  makes  a  sprightly 
jelly  for  mutton,  venison,  and  wild  ducks,  giving  zest  to  the 
flesh  and  acidifying,  as  it  were,  their  fats,  which  are  more  or 
less  neutral,  and  do  not  emulsify  properly  with  the  bile  and 
pancreatic  juice  until  acidulated  somewhat.  The  black  cur- 
rant, Rihcs  nigruui,  is  quite  astringent,  and  is  a  favorite  in- 
gredient in  throat  lozenges  and  such  remedies.  The  English- 
man loves  its  jelly.  The  currant  analyzes  about  as  follows  in 
the  dried  state:  Water,  27.9;  protein,  1.2;  fat,  3;  carbo- 
hydrates, 65.7;   ash,  2.2.     Fuel  value  per  pound,  1370. 

The  Cranberry. — The  cranberry  we  all  know  of  from  the 
delicious  sauce  it  makes  and  which  serves  the  same  purpose 
in  digestion  as  currant  jelly  and  other  sauces.  It  comes  with 
many  varieties  from  the  Vaccininin  inacvocavpon  and  other 
shrubs  which  grow  wild  in  boggy  places  in  the  temperate 
zone  throughout  the  world.  In  the  bogs  the  organic  decay 
aromid  it  gives  it  its  organic  acid ;  cultivation  improves  the 
berry  greatly,  and  the  finest  I  ever  saw  were  sent  me  by  a 
friend  from  his  bogs  on  Cape  Cod.  Cranberries  ship  best 
over  the  seas  packed  in  water ;  they  analyze  as  follows : 
Water,  88.5;  protein,  .5;  fat,  .7;  carbohydrates.  10. i  ;  ash.  .2. 
Fuel  value  per  pound,  225. 

The  Cherry. — This  fruit  especially  delights  the  small  boy. 
and  gives  him  many  a  bad  turn,  not  so  much  because  the  fruit 
is  innately  bad  as  that  the  small  boy  is  innately  reckless  in 
his  eating  of  it.  Here  is  the  analysis  of  the  edible  portions : 
Water,    86.1:    protein,    i.i;    fat,    .8:    carbohydrates,    11.4; 

351 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

ash,  .6.  Fuel  value  per  pound,  265.  Not  a  bad  showing  for 
health.  The  bad  reputation  of  the  cherry  as  an  article  of 
food  is  doubtless  caused  by  the  habit  of  eating  it  out  of  con- 
dition as  to  ripeness,  and  as  to  its  fermenting  or  rotting  state, 
and  because  it  is  a  most  hospitable  host  to  pathogenic  and  other 
germs.  Before  it  is  eaten  it  should  be  thoroughly  washed 
and  cleansed.  Botanically  it  is  the  Primus  cerasus,  or  Prunus 
vulgaris,  and  is  said  to  be  of  Asiatic  origin.  The  wild  cherry- 
tree  is  the  Prunus  virginiana,  or  the  Cerasus  virginiana. 
There  is  much  prussic  acid  in  the  cherry-wood,  particularly 
in  the  bark  of  the  wild  cherry,  which  is  taken  advantage  of 
for  medicinal  purposes.  Our  finest  cherries  for  eating  come 
undoubtedly  from  California,  where  the  soil  and  climate  suit 
them  exactly.  They  come  to  us  of  the  black  and  white  varie- 
ties, the  finer  specimens  being  the  Governor  Wood,  Black 
Tartarian,  Cleveland  Bigarreau,  Reine  Hortense,  Llewel- 
ling.  Napoleon  Bigarreau,  and  others.  These  are  all  mag- 
nificent fruits,  and  give  us  good  healthy  luxuries  of  the 
fruit  kind.  In  the  country  east  of  the  Rockies,  including  our 
own  near-by  neighborhoods,  these  grand  cherries  of  the 
French  and  other  types  do  not  do  so  well  as  young  trees. 
They  appear  to  be  weak,  and  yield  to  sun  scald  and  other 
destructive  diseases.  I  have  planted  a  number  of  them,  and 
very  few  live,  while,  on  the  other  hand,  on  the  same  fruit- 
farm  there  are  trees  vigorous  and  hardy  of  the  best  of  the 
old  heart  cherries  approaching  a  century  old.  I  cannot  help 
but  think  there  is  some  inherent  weakness  in  our  young  trees 
brought  about  by  improper  propagation  and  by  the  devital- 
izing processes  of  grafting  and  budding.  We  grow  fine  sour 
cherries  where  we  cannot  grow  the  sweet  ones,  the  best  of 
the  sour  cherries  being  the  Early  Richmond  and  May  Duke. 
The  Quince. — This  fruit  is  useful  only  for  preserves  and 
for  its  many  medicinal  qualities.  Its  seeds  produce  an  emol- 
lient much  used  by  oculists  as  quince-seed  mucilage.  In  treat- 
ing it,  the  fruit  requires  parboiling  to  set  the  albumin  as  a 
preliminary  to  sugaring  it.  The  best  varieties  are  the  Or- 
ange, the  Champion,  the  Meech,  and  the  Rea. 

352 


FORTY    YEARS    IN    THE   MEDICAL   PROFESSION 

The  Blackberry. — This  comes  under  the  genus  Rubus. 
The  wild  blackberry  is  the  Rubus  villosus.  It  is  cultivated, 
and  the  evolution  to  the  higher  types  has  been  rapid.  It  is 
used  medicinally  for  its  astringency,  the  fruit,  the  leaves, 
and  the  roots.  The  best  varieties  we  find  in  the  market  are 
the  cultivated  Wilsons,  Wilson,  Jr.,  and  the  Early  Harvest. 
The  common  wild  blackberry  has  a  fine  flavor,  more  delicate 
than  the  cultivated.  All  the  berries,  both  wild  and  culti- 
vated, are  much  used  for  jams,  wine,  and  brandy,  each  being 
more  or  less  astringent.  The  analysis  is  as  follows :  Water, 
89.9,  protein,  .9;  fat,  2.1;  carbohydrates,  7,5;  ash,  .6.  Fuel 
value  per  pound,  245. 

Dewberry. — This  is  about  the  same  berry  in  analysis  as 
the  blackberry,  but  it  is  perhaps  a  little  sweeter  and  larger 
in  the  wild  state,  and  trails  along  the  ground,  whilst  the 
blackberry-canes  grow  upright.  The  Lucretia  is  the  chief 
variety  in  the  market.  They  are  both  known  among  coun- 
trymen as  brambles.  Botanically  the  dewberry  is  the  Rubus 
trivialis,  or  Rubus  canadensis. 

The  Raspberry. — This  comes  under  the  same  genus  as 
the  blackberry,  the  Rubus.  The  raspberry  is  the  Rubus  idcous. 
The  red  wild  raspberry  is  the  Rubus  strigosus,  and  the 
black  wild  raspberry  is  the  Rubus  occidentalis.  The  fine  speci- 
mens we  see  in  the  cultivated  reds  and  black  caps  doubtless 
come  from  these  as  the  result  of  selection  and  cultivation. 
They  are  too  familiar  to  all  to  need  any  description,  and  I 
need  only  say  that  the  flavor  of  the  raspberry  is  among  the 
most  delicate  and  delicious  of  all  berries.  They  analyze  as 
follows:  Water,  85.8;  protein,  i;  carbohydrates,  12.6; 
ash,  .6.  Fuel  value  per  pound,  255.  The  best  red  varie- 
ties are  Miller,  Marlboro,  Brandywine,  Turner,  Cuthbert, 
or  Queen  of  the  Market,  a  very  large  and  beautiful  berry, 
but  apt  to  be  soft  if  carried  far.  Shaffer's  Colossal  is  the 
largest;  Hansell  is  the  earliest.  Of  the  black  caps,  the  best 
are  probably  Souhegan  and  Gregg.  You  will  occasionally 
see  a  yellow  or  amber  raspberry  in  the  market;  they  are 
sports.  The  Golden  Queen  is  a  fine  one,  and  is  a  sport  of 
23  353 


FORTY    YEARS   IN   THE   MEDICAL   PROFESSION 

the  Ciithbert.  It  is  a  luscious  berry,  and  an  odd  one  for  dec- 
orative purposes.  Raspberry  vinegar,  raspberry  syrup,  rasp- 
berry wine,  and  raspberry  jam  are  products  of  the  raspberry. 
The  Strawberry. — The  strawberry  is  a  luscious  and  in 
every  way  an  interesting  berry.  Let  me  say,  as  a  matter  of 
precaution  in  regard  to  the  strawberry,  the  raspberry,  the 
blackberry,  and  all  such  berries,  care  should  be  exercised  as 
to  eating  large  quantities  of  them,  and  particularly  of  rasp- 
berries and  blackberries.  Children  and  elderly  people  should 
be  particularly  cautioned,  as  the  large  bowels  are  liable  to 
become  packed  with  the  seeds  and  cause  inconvenience  and 
trouble.  They  also  cause  urticaria  in  many,  probably  from 
some  idiosyncrasy  of  the  individual,  or  from  something  they 
may  accidentally  meet  in  the  bowel,  and  set  up  a  ptomaine 
poisoning  on  a  limited  scale,  evincing  itself  by  the  indigestion 
and  the  rash  accompanying  it.  Let  us  return  to  the  straw- 
berry. Its  chemical  composition  is  as  follows :  Water,  90.9 ; 
protein,  i;  fat,  .7;  carbohydrates,  6.8;  ash,  .6.  Fuel  value 
per  pound,  175.  The  various  species  belong  to  the  genus 
Fragaria,  and  are  of  the  rose  family.  The  fruit  as  we  eat  it 
is  not  really  the  true  fruit  of  the  vine.  The  pistils  are  placed 
tipon  a  convex  receptacle,  and  this,  when  the  ovaries  are  ripe, 
is  much  enlarged,  and  this  is  the  fruit  as  we  eat  it  or  call  it. 
The  true  fruit  is  the  little  ripened  ovaries  which  look  like 
seeds  scattered  all  over  what  we  eat  as  the  fruit.  Under  cul- 
tivation the  stamens  of  some  varieties  abort,  and  the  blossom 
is  thus  not  self-fertile;  that  plant  is  dioecious,  and  in  raising 
the  berries  practically,  it  is  necessary  with  these  dioecious  plants 
to  set  a  fertile  or  some  monoecious  kind  about  every  third  or 
fourth  row.  This  makes  the  plant  an  interesting  study,  as 
the  Indian-corn  plant  is  an  interesting  study.  Here  the  silk 
is  the  pistils,  and  these  must  be  impregnated  by  the  pollen 
-of  the  antlers  at  the  top  of  the  stalk,  or  no  grains  of  corn  will 
be  produced.  Here  the  stamens  and  pistils  are  in  different  flow- 
ers or  different  parts  of  the  same  plant.  The  best  varieties  of 
strawberries  are  named  below,  and  to  appreciate  the  great  con- 
sumption of  the  berries  it  is  only  necessary  to  watch  the  line  of 

354 


FORTY    YEARS    IN    THE   MEDICAL   PROFESSION 

travel  on  the  railroads  leading  from  the  Delaware  and  Chesa- 
peake Peninsula  or  from  South  Jersey.  Thousands  of  car- 
loads pass  every  season  for  the  markets  of  the  great  cities.  The 
Michel  is  the  first  of  the  early  berries,  and  is  an  all-round  good 
berry.  It  has  a  perfect  blossom.  The  Ideal  is  one  of  J.  W. 
Kerr's  new  berries,  with  a  perfect  blossom.  Oriole  is  another, 
with  imperfect  blossoms.  The  Sharpless  is  an  old,  very  large, 
and  well-tried  variety.  The  Bubach  No.  5  is,  I  believe,  the 
largest  and,  taking  everything  into  consideration,  the  finest 
berry  yet  introduced.  It  is  imperfect  as  to  blossom.  The 
Gandy  is  the  best  berry  we  see  late  in  the  market,  and  has  a 
perfect  blossom.  The  Kentucky  is  the  firmest  late  berry,  and 
has  a  pistillate  bloom.  Warfield  No.  2  is  a  good  berry,  pis- 
tillate. Wilson  Albany  is  one  of  the  very  oldest  varieties  and 
a  very  firm  berry,  and  carries  a  long  distance  well ;  stam- 
inate.  The  Haverland  is  a  fine  berry  of  the  lady-finger  order ; 
pistillate.  The  Lady  Thompson,  staminate,  is  a  good  berry 
from  North  Carolina  early  in  the  season,  but  not  good  raised 
in  the  Middle  States.  These  early  berries,  some  coming  from 
Florida  in  January,  must  be  firm  to  have  carrying  capacity. 
Warfield  No.  2,  I  think,  comes  from  Florida  in  January  and 
February.  The  Crescent  is  probably  the  most  productive 
berry  for  the  grower;  it  is  small,  a  good  berry,  but  not  at- 
tractive ;  it  is  pistillate.  The  Hovey  is  the  oldest  of  the  large 
varieties,  very  dark  red,  and  very  large  and  luscious.  It  is 
rare  now.  Lovett,  a  good  berry  from  New  Jersey.  Van 
Deman,  named  for  Professor  Van  Deman,  late  United  States 
Pomologist;  staminate.  The  best  new  strawberries  in  our 
markets  are  the  Bismarck,  Tennessee  Prolific,  and  Johnson's 
Early.  All  these  have  perfect  bloom.  The  largest  and  finest 
strawberries  I  ever  saw  were  in  California  fortv  vears  ago. 
They  were  a  light  cream-color,  nearly  white,  and  immensely 
large,  with  a  delicious  flavor.  I  have  never  seen  berries  like 
them  in  any  other  country.  Whether  they  were  sports  or 
originals  I  do  not  know.  California  is  a  great  State  for  all 
fruits,  and  I  believe  you  can  purchase  strawberries  in  the  San 
Francisco  markets  every  month  in  the  year. 

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FORTY   YEARS   IN    THE   MEDICAL    PROFESSION 

How  and  why  Fruits  decay. — Dr.  G.  C.  Caldwell,  of  the 
Cornell  Experiment  Station,  has  given  us  some  good  points 
on  this  head.  The  changes  which  take  place  in  the  ripening 
of  fruit  are  in  some  respects  similar  to  the  changes  of  rotting. 
In  ripening,  the  abundant  starch  of  the  green  fruit  is  changed 
to  cane-sugar;  later  a  great  part  of  the  cane-sugar  becomes 
glucose.  These  changes  may  go  on  whilst  the  fruit  is  still 
on  the  tree,  or  in  the  storage-room  after  it  has  been  picked. 
This  change  of  cane-sugar  to  glucose  does  not  help  the  fruit 
in  flavor,  for  glucose  is  less  sweet  than  cane-sugar.  The 
riper  fruit  gets,  short  of  decay,  the  sweeter  it  gets,  not  be- 
cause the  cane-sugar  changes  to  glucose,  but  because  so  much 
of  the  starch,  which  is  tasteless,  becomes  sugar  and  some  of 
the  acids  of  the  fruit  are  decomposed.  As  fruit  goes  on  to 
rot,  what  cane-sugar  there  is  goes  to  glucose,  and  then  this 
glucose  is  decomposed.  The  proteids  and  the  tannin  also  are 
decomposed,  and  new  chemical  compounds  are  produced  which 
cause  the  brown  color  and  the  unpleasant  taste  of  the  decay 
which  has  now  set  in.  Different  species  of  fungi  cause  this 
rotting  of  the  fruit,  and  the  three  important  ones  are  Pencil- 
Hum  glaucum,  Botrytis  vulgaris,  and  Oilium  fructigenum. 
This  last-mentioned  one  exists  even  on  the  fruit-trees,  and 
attacks  both  the  ripe  and  the  green  fruit,  and  is  even  found 
on  the  blossoms.  It  goes  in  at  the  stem  of  the  fruit,  into  the 
twig  and  the  leaves,  and  kills  both,  producing  the  twig  blight 
and  leaf  blight  so  common.  Flies  and  wasps  and  other  in- 
sects carry  this  fungus  from  tree  to  tree.  The  more  wasps 
and  flies  there  are  about,  the  more  decayed  fruit  there  is. 
These  fungi  of  decay  produce  a  poison  which  kills  the  cells 
of  the  leaves  and  of  the  twigs  and  of  the  fruit.  Now,  as  to 
spraying  for  these  fungi  with  copper  and  arsenic,  even  if  we 
spray  late,  when  the  fruit  is  grown,  there  is  little  trace  of  the 
poisons  on  the  fruit,  and  they  are  safe  to  eat.  I  have  sev- 
eral years  since  experimented  with  fungicides  sprayed  on 
apples  in  winter  storage  in  Delaware,  and  at  the  time  I 
thought  the  results  were  good.  The  great  increase  in  these 
fungi  over  the  times  of  fifty  years  ago,  together  with  the 

356 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

higher  temperatures  of  our  cellars  where  our  fruit  is  often 
stored,  are  the  great  reasons  why  our  fruit  does  not  keep  now 
Hke  it  did  in  the  cellars  of  our  grandfathers.  General  cold 
storage  is  coming  in  to  remedy  all  this  and  to  decrease,  I 
trust,  the  development  of  the  fungi  of  decays. 

MUSHROOMS. 

The  Edible  and  the  Poisonous  Fungi. — Mushrooms  are  so 
universally  used  for  food  that  it  is  of  the  greatest  importance 
that  not  only  physicians  but  laymen  should  know  at  least 
sufficient  about  them  to  avoid  those  growing  wild  which  are 
poisonous,  and  to  distinguish  those  which  are  edible.  Bulle- 
tin No.  15,  Department  of  Agriculture,  by  Dr.  W.  G.  Farlow, 
gives  the  best  resume  of  the  subject  I  am  acquainted  with, 
and  to  him  I  am  indebted  for  assistance.  Mushrooms  are 
toadstools,  and  therefore  the  names  do  not  distinguish  them. 
The  best  known  and  edible  of  the  toadstools  are  what  we 
know  as  mushrooms,  so  called  in  the  markets.  There  are 
many  other  toadstools  not  known  in  market  as  mushrooms, 
which  are  edible,  and  many  more  of  them  are  not  poisonous, 
even  if  not  very  palatable.  How  do  you  tell  the  edible  from 
the  poisonous  fungi  ?  We  do  not  exactly  know  scientifically, 
but  we  know  in  regard  to  many  of  them  empirically,  because 
some  one  has  eaten  this  one  and  lived  to  tell  the  story,  and 
another  person  has  eaten  that  one  and  died  from  the  effects. 
The  number  tried  empirically  is  small  in  comparison  to  the 
whole  number  of  species  of  toadstools.  As  to  this  great  num- 
ber of  unknowns,  we  might  say  that  this  one  is  not  poisonous 
because  it  resembles  that  one  we  know  to  be  harmless,  and 
this  one  is  poisonous  because  it  resembles  one  we  know  to 
be  poisonous.  This  reasoning  may  not  always  be  practically 
safe.  Mushrooms  and  toadstools  (I  use  the  word  mushroom 
to  apply  to  the  edible  fungi,  or,  rather,  the  ones  we  are  fa- 
miliar with  in  market  or  on  our  tables,  and  the  word  toadstool 
to  apply  to  those  not  generally  used  as  food,  whether  edible 
or  not  edible)  belong  to  the  group  of  fungi  known  as  Hyme- 
nomycctes.    They  grow  in  the  ground  or  on  the  bark  of  trees. 

357 


FORTY   YEARS    IN    THE   MEDICAL    PROFESSION 

There  is  first  a  ball,  which  gradually  enlarges  and  shoots  up 
into  a  stem  bearing  at  the  top  the  umbrella,  or  pileus.  This 
gradually  expands,  in  some  species  largely,  and  in  others 
keeps  more  of  a  ball  shape.  The  mushroom,  or  toadstool 
comes  from  fine  threads.  These  threads  are  the  spawn,  or 
the  mycelia,  the  spores  of  fungi.  Each  thread  is  called  a 
hypha. 

The  word  mushroom  is  almost  universally  used  to  ex- 
press an  upstart  of  any  kind,  whether  in  real  life  or  other- 
wise. This  would  seem  to  indicate  that  we  all  think  of 
the  mushroom  as  springing  up  in  a  night.  This  is  not  the 
case.  The  button  developing  from  the  mycelia  takes  often 
a  long  time,  even  weeks,  months,  or  years,  before  it  comes 
from  the  mycelia  or  spawn  in  the  ground  to  the  top.  True, 
the  mycelia,  or  spawn,  are  the  whole  plant,  and  the  mush- 
rooms are  the  fruit  only,  the  reproductive  bodies  like  the 
apples  of  the  apple-tree.  The  spores,  the  mycelia,  the  spawn, 
reside  in  the  mushrooms  or  fruit  of  the  fungus.  The  buttons, 
in  the  parlance  of  trade,  are  these  young  non-expanded  mush- 
rooms, and  mushrooms  are  the  expanded  buttons.  In  Europe 
buttons  are  most  used.  In  this  country  we  use  mostly  the 
expanded  fruit.  In  the  toadstool  family  the  under  side  of 
the  umbrella,  or  the  pileus,  bears  the  spores  or  seeds.  In 
some  species  these  are  like  the  spokes  of  a  wheel,  and  radiate 
to  the  circumference  from  the  top  of  the  stalk.  In  others  they 
are  packed  in  and  together  like  tubes  in  a  boiler,  in  others 
like  teeth,  whilst  in  still  others  the  surface  is  only  set  in 
wrinkles.  The  wheel-spoke  or  gill  group  are  called  Agari- 
cini,  or  the  agarics;  the  tube  group  are  the  Polyporei,  the 
teeth  group  the  Hydnei,  and  the  wrinkle  the  Thelephorei. 

There  are  some  toadstools  with  no  stalk  at  all,  yet  even 
some  of  these  mere  balls  are  edible,  but  no  one  but  an  expert 
should  even  think  of  eating  them.  Nearly  all  of  the  edible 
mushrooms  belong  to  the  agarics  and  the  polyporei.  No  one 
when  beginning,  and  not  yet  an  expert,  should  gather  buttons 
for  food,  for  it  is  then  so  difficult  to  distinguish  the  species. 
Of  course,  this  does  not  apply  to  cultivated  mushrooms,  for 

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FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

the  species  is  known  and  raised  only  for  food.  Again,  do  not 
eat  old  decayed  mushrooms,  as  even  the  edible  ones  when 
old  may  develop  poisons. 

The  common  mushroom,  Agaricus  campestris,  is  really  the 
only  species  cultivated  and  sold  in  our  markets  during  win- 
ter. In  summer  it  grows  wild,  is  most  plentiful  in  June, 
July,  August,  and  September,  and  is  found  more  frequently 
in  old  pasture-fields  than  in  other  places.  As  a  rule,  it  does 
not  grow  in  the  woods.  The  stalk  and  umbrella  are  white 
or  cream-color,  and  the  gills  are  pink,  going  on  to  dark  brown 
or  purplish  brown  as  the  mushroom  gets  older.  This  pink  or 
brown  color  is  due  to  the  spores  on  the  gills.  The  stalk  is 
cylindrical  and  solid,  and  near  the  umbrella  is  a  membranous 
ring,  and  below  this  there  is  no  membrane  or  scales.  Re- 
member this.  They  grow  singly  or  in  clusters  of  several. 
Before  the  umbrella  opens  the  gills  are  covered  by  the  veil; 
when  the  mushroom  expands,  the  veil  ruptures  and  the  red 
gills  are  exposed.  What  is  left  of  the  veil  clings  around  the 
stalk  and  forms,  a  little  below  the  umbrella,  the  ring  before 
spoken  of.  Some  fragments  of  the  veil  also  remain  attached 
to  the  margin  of  the  umbrella,  giving  it  a  slightly  fringed 
appearance.  When  looking  for  this  mushroom  see  that  the 
gills  are  pink  or  dark  brown  and  not  white,  that  the  stalk 
is  round  and  solid  and  has  the  ring  below  the  umbrella,  and 
that  it  has  no  bulb  at  the  ground  end  and  no  scales  or  bag 
of  a  membranous  material.  It  never  grows  on  old  logs  or 
trees. 

The  two  poisonous  toadstools  in  danger  of  being  mistaken 
for  the  common  mushroom  are  the  Amanita  phaUoides,  the 
deadly  agaric,  and  the  Amanita  muscaria,  the  fly  agaric.  The 
former  is  the  worst,  and  the  latter  is  the  most  common.  The 
fly  agaric  is  quite  common;  it  grows  on  roadsides,  on  the 
borders  of  fields,  but  not  often  in  pastures,  and  not  usually 
with  the  common  mushroom.  It  grows  very  often  among 
pine-trees  and  under  evergreens.  It  grows  singly  and  is  often 
very  large.  Its  gills  are  ivhite,  not  pink.  Its  stem  is  hollow, 
not  solid  like  the  common  mushroom  stem,  there  is  ahvays  a 

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FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

bulb  at  the  ground  end,  and  scales  on  it.  The  color  of  the 
umbrella  is  brilliant  yellow  to  orange,  and  a  deep  red,  espe- 
cially orange.  The  surface  of  the  umbrella  is  polished  with 
a  number  of  warty  scales,  which  cannot  be  rubbed  off.  There 
is  a  large  membranous  collar  hanging  down  from  the  upper 
part  of  the  stem.  This  is  the  mushroom  most  frequently 
causing  poison,  but  surely  no  one  having  the  least  experi- 
ence in  gathering  mushrooms  could  mistake  it  for  the  com- 
mon edible  mushroom.  Pick  it  up,  and  it  is  light,  and  the 
stem  has  no  strength,  and  bends  like  a  piece  of  cooked  maca- 
roni. The  common  mushroom  has  a  firm,  solid  stem.  This 
fly  agaric  strongly  resembles  the  Amanita  ruhescens,  one  of 
the  most  delicious  of  mushrooms,  with  a  flesh  of  red  tinge. 
None  but  an  expert  should  gather  this;  they  may  pick  the 
poisonous  fly  agaric  for  it. 

There  is  another  delicious  mushroom  not  common  in  the 
North,  but  often  found  in  the  South, — the  Amanita  ccesarea, 
or  royal  agaric.  Here  the  gills,  ring,  and  stalk  are  yellow, 
not  white,  no  scales  on  the  stalk,  but  a  bag-like  membrane 
through  which  the  stalk  runs.  The  deadly  agaric  has  the 
umbrella  without  warts,  the  gills  white,  the  stalk  hollow,  with 
a  large  ring  and  a  bulb  at  the  ground  end,  with  a  bag-like 
upper  margin,  and  a  hollow  stalk  long  and  slender.  No  one 
can  mistake  this  hollow  stalk  in  any  mushroom  for  the  solid 
stalk  of  the  edible  common  mushroom  after  once  he  has  felt 
and  compared  them.  There  are  no  scales  or  warts  on  the 
common  mushroom;  then  the  color  of  the  gills,  the  general 
appearance,  its  standing  with  head  erect,  whilst  the  hollow- 
stem  ones  have  a  mean,  leaning,  cast-down  look,  showing 
them  the  villains  they  are.  The  common  mushroom  often 
has  the  umbrella  four  inches  broad ;  the  stalk  is  stout,  round, 
and  smooth  below  the  ring,  and  not  usually  as  long  as  the 
umbrella  is  broad.  The  common  mushroom  has  an  odor  of 
its  own,  a  woody  odor,  a  raw  odor,  and  so  has  the  deadly 
agaric.  The  fly  agaric  has  little  or  no  odor.  All  these  three 
— the  fly  agaric,  the  deadly  agaric,  and  the  common  mush- 
room— have  a  taste  not  unpleasant  in  the  raw  state,  and  un- 

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FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

fortunately,  when  cooked  each  has  good  flavor  and  not  dis- 
tinctive. 

The  Horse  Mnsliroom,  Agaricus  arvensis,  lool<s  like  the 
common  mushroom,  the  Agaricus  campestris,  but  is  larger, 
and  is  often  taken  for  and  eaten  for  the  common  mushroom. 
It  is  edible  and  safe.  It  grows  along  hedges  and  in  cultivated 
fields.  The  umbrella  is  shining  white  and  the  stem  is  a  little 
hollow.  The  gills  are  at  first  white,  a  very  suspicious  quality, 
but  they  brown  up  as  it  gets  older.  The  ring  is  double,  not 
single,  as  in  the  common  mushrooms. 

There  is  another  common  mushroom,  an  edible  one,  the 
Hypholoma  appendiculatnm.  It  grows  in  clusters  around 
stumps  in  grass  fields.  The  color  is  transparent  white,  with 
a  purple  or  a  brownish  tinge  when  wet.  The  umbrella  is 
thin  and  bell-shaped,  and  the  edges  roll  up  somewhat.  The 
gills  are  a  purple-brown;  it  has  no  ring,  and  the  stalk  is 
hollow. 

The  Horsetail  Fungus,  the  maned  agaric,  Coprimis  coma- 
tus,  is  edible,  and  grows  along  the  roadside  in  grass  in  dense 
clusters.  The  umbrella  in  this  species  remains  closed,  not 
open,  and  when  commencing  to  decay  it  rolls  outward,  and 
the  fungus  liquefies  in  a  dark  fluid.  This  is  the  way  it  de- 
cays. The  umbrella  is  white,  with  fringy  scales.  The  gills 
are  broad,  close  to  the  stalk,  and,  like  the  common  mushroom, 
turn  from  pink  to  dark.  The  stalk  is  long  and  hollow,  and 
has  a  ring  which  can  be  moved  up  and  down.  A  few  appear 
in  early  summer,  but  it  is  most  plentiful  in  the  fall.  Two  other 
specimens  of  Coprimis  are  found,  and  mostly  around  walls 
and  houses, — Coprimis  afranientarius.  The  stalk  is  short  and 
stout,  and  it  is  edible.  The  color  is  ashy  and  dark,  and  it  has 
no  scales,  but  is  furrowed.  Coprimis  micaceous  is  a  small  one 
and  is  edible,  with  the  umbrella  light  brown  or  darker.  These 
species  are  quite  common  and  grow  around  houses,  but  I  do 
not  think  they  are  so  palatable  as  to  entail  the  certain  risk  the 
amateur  runs  in  eating  such. 

I  think  ninety-nine-one-hundredths  of  the  wild  mushrooms 
we  eat  are  the  Agaricus  cauipcstris,  the  common  mushroom, 

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FORTY   YEARS    IN    THE   MEDICAL   PROFESSION 

and  any  one  can  tell  them  after  a  very  little  practice.  Before 
eating  any  other  kind  I  want  them  passed  upon  by  an  expert 
who  has  very  frequent  practice.  Our  most  poisonous  species 
of  toadstools  have  a  wrapper,  as  it  were,  around  the  base  of 
the  stalk,  called  a  volva;  if  in  addition  they  have  white  gills 
and  spores  and  a  bulbous  base,  with  scales,  they  should  not  be 
eaten. 

The  Parasol  Fungus,  Lepiota  procera,  is  large  and  tall,  and 
grows  in  grass ;  it  is  not  poisonous,  but  is  tough  and  not  de- 
sirable. It  is  white  or  brown.  The  umbrella  is  scaly,  and 
the  ring  is  free  on  the  stalk. 

The  Chanterelle,  the  Cantharellus  ciharius,  grows  in  the 
woods  in  summer.  It  is  yellow  and  has  a  crumpled  margin. 
The  upper  surface  is  depressed  and  the  gills  run  down  over 
the  stalk.  It  is  not  good  enough  to  risk  eating  it,  if  gathered 
by  the  average  hunter. 

The  Fairy  Fungus,  Marasmius  oreades,  grows  in  the  grassy 
lawns  in  rings,  which  are  called  fairy  rings.  It  is  tough  and 
not  good,  though  edible.  The  stalk  is  tubular,  and  the  um- 
brella or  pileus  is  thin.  It  is  of  a  drab  color ;  the  spores  are 
white.  To  determine  the  color  of  the  spores  of  a  mushroom 
press  it  on  a  piece  of  white  paper  and  allow  it  to  remain  a 
while,  and  the  color  of  the  spore  will  be  shown. 

Fungi  with  Milky  Juice. — These  are  of  the  genus  Lacta- 
rius.  The  milk  is  usually  white,  but  may  be  red  or  blue.  In 
some  species  it  is  very  acrid.  They  are  safe,  but  not  good. 
There  is  one  specimen  said  to  be  good, — the  Lactarius  deli- 
cosus.  It  is  a  mountain  fungus.  The  milk  is  red  and  after- 
wards turns  to  green.  The  fungus  is  red.  The  Russules  are 
mostly  small  and  grow  in  swamps  and  woods.  The  gills  are 
yellowish.  Some  are  edible,  and  some  are  poisonous.  The 
Oyster  Fungus,  Pleurotus  ostreatus,  has  no  central  stalk,  but 
grows  to  trees  attached  by  a  short  stalk  at  the  side.  They 
grow  in  clusters  attached  to  a  tree,  like  oysters  attached  to 
rocks.  They  are  yellowish  in  color,  and  the  clusters  are  often 
a  foot  or  more  wide.  The  gills  are  long.  It  is  edible,  but  not 
very  palatable,  and  not  worth  any  risk.     The  Polyporei,  or 

362 


FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

tube-bearing  fungi,  as  distinguished  from  tiic  fungi  with 
gills,  have  central  stalks  and  some  only  lateral,  like  the  oyster 
fungi.  Most  of  the  species  are  not  palatable  if  edi1>le.  The 
edible  species  belong  to  the  genus  Boletus.  They  are  soft 
and  fleshy,  and  grow  on  the  ground  in  woods  and  fields. 
Some  are  edible  and  some  are  poisonous.  They  are  not 
worth  risking  as  an  article  of  diet.  Boletus  subluteus  is  edible, 
but  not  very  palatable,  not  worth  eating. 

The  Steinpilz  of  the  Germans  is  very  large.  The  stalk  is 
stout.  The  tubes  are  two  inches  long;  they  are  white,  and 
then  become  yellow.  It  is  edible,  but  not  worth  eating.  This 
is  the  true  Cepe.  In  the  boleti,  if  the  mouths  of  the  tubes  are 
red,  do  not  eat  it.    The  boleti,  as  a  rule,  are  rather  dangerous. 

The  Beefsteak  Fungus,  Fistulina  hepatica,  grows  on 
stumps,  particularly  on  oak  and  chestnut  stumps.  When 
young  the  upper  side  is  of  a  peach-color,  growing  to  a  deep 
red  with  age.  The  tubes  are  flesh-color  and  are  on  the  under 
side.  The  surface  looks  like  a  cooked  tongue  or  like  a  beef- 
steak.   It  is  safe  to  eat. 

Teeth-bearing  fungi,  Hydnei,  hedgehog  fungi,  are  some  of 
them  edible,  but  not  palatable.  Their  color  is  white  to  brown 
and  red  and  yellow.  The  two  most  common  are  Hydniim 
imbricatum  and  Hydnum  repandmn.  They  are  found  in 
swamps.  The  coral-shaped  fungi  of  the  family,  Thelephorei, 
are  not  poisonous.  I  do  not  think  them  worth  eating,  but 
some  experts  say  many  of  them  are  good. 

Morels  and  Truffles. — The  morels  are  among  the  best 
of  fungi  to  eat.  Botanically  they  are  not  close  to  the  toad- 
stools. They  may  be  called  the  tripe-like  fungus,  and  the 
honey-comb  runs  into  the  covering.  Hunt  for  them  in  the 
spring  and  early  summer  in  woodland  that  has  been  burned 
over.  The  stalk  is  white  and  granular.  Truffles,  the  great 
delicacy  of  Europe  of  the  fungi,  are  not  found  in  the  United 
States,  at  least  not  the  prized  ones.  They  are  like  small  pota- 
toes, and  are  hunted  by  trained  dogs  and  pigs,  and  dug  out 
of  the  ground.  If  found  with  us,  it  will  probably  be  on  cal- 
careous soil,  among  hills  covered  with  oak-trees. 

363 


FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

Puff-Balls. — Gasteromycetes,  or  puff-balls,  as  a  rule, 
have  -no  stalk ;  they  lie  on  the  ground.  The  powder  comes 
with  age  and  is  chiefly  composed  of  mycelia  or  spores.  The 
largest  is  the  Lycoperdon  giganteum,  and  grows  to  a  circum- 
ference of  forty  inches.  The  flesh  is  white  or  yellowish  and 
firm,  and  edible  before  it  becomes  powder.  Another  puff-ball, 
edible,  as  most  of  them  are  before  the  powder  forms,  is  Lyco- 
perdon cyafhiforme.  There  is  one  species  of  puff-balls  poi- 
sonous, and  it  grows  around  houses,  the  Scleroderma  vulgare. 
The  exterior  is  yellow  and  warty,  and  the  inside  is  purple  or 
black,  with  white.  None  of  these  puff-balls  are  sufficiently 
attractive  as  food,  unless  one  is  starving,  to  cause  one  to  run 
a  risk  of  eating  Scleroderma  vulgare  for  Lycoperdon  cyafhi- 
forme. Dr.  Farlow  well  says,  "  When  you  are  in  doubt,  never 
eat  a  fungus."  This  is  the  only  rule  needed.  Truly  they  are 
only  a  luxury  anyhow,  not  a  staple  food.  There  is  no  danger 
in  eating  cultivated  ones,  for  then  there  can  be  no  mistake: 
no  poisonous  ones  are  cultivated.  The  cultivated  common 
mushroom,  the  Agaricus  campestris,  is  as  finely  flavored  when 
cultivated  as  when  grown  in  its  wild  state. 

The  tests  to  distinguish  poisonous  from  non-poisonous 
mushrooms  or  toadstools  in  common  vogue,  as  of  cooking  a 
silver  spoon  with  them,  the  blackening  of  the  spoon  being  a 
sign  of  poison,  are  utterly  unreliable.  Cooking  in  milk  or  vine- 
gar may  do  more  harm  than  good  if  the  fungi  be  poisonous. 
There  are  two  classes  of  poisonous  fungi,  the  irritant  and  the 
narcotic.  The  narcotic  are  the  most  dangerous.  The  irri- 
tant may  work  their  own  cure  by  causing  vomiting  soon  after 
they  have  been  eaten.  The  narcotic  may  cause  serious  symp- 
toms after  ten  or  twelve  hours  through  the  nerve-centres. 
The  irritant  fungi,  as  a  rule,  have  a  pungent,  disagreeable 
taste,  the  narcotic  a  rather  pleasant  taste.  Muscarin  is  the 
chief  poisonous  active  principle  of  the  Amanita  muscaria. 
Muscarin  is  a  colorless  alkaloid,  which  forms  salts  with  acids. 
Muscarin  is  not  poisonous  to  flies,  but  this  mushroom  con- 
tains another  poison  which  is  volatile  and  kills  flies.  Mus- 
carin can  be  made  synthetically  by  treating  cholin  with  nitric 

364 


FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

acid.  Poisoning  by  the  fly  mushroom  comes  on  in  from  a 
half-hour  to  two  hours,  up  to  ten  hours.  First  come  colic, 
vomiting,  and  diarrhoea,  then  contracted  pupils  and  saliva- 
tion; then  the  patient  becomes  drunk,  as  from  alcohol,  the 
vision  is  disturbed,  and  convulsions  may  supervene;  stupor 
comes  on  with  apoplectic  symptoms,  and  either  symptoms  of 
collapse  and  death  follow  or  the  patient  gradually  recovers 
from  his  stupor  and  recovery  takes  place.  The  fatal  result 
is  often  postponed  until  the  second  or  third  day. 

As  to  treatment,  evacuate  the  stomach  by  emetics  or  apo- 
morphine  hypodermically ;  if  free  vomiting  does  not  take 
place,  use  the  stomach-pump  and  give  croton  oil  to  evacuate 
the  bowels.  Atropia  is  the  antidote  to  muscarin;  give  it 
hypodermically.  Combat  tendency  to  heart  failure  with  digi- 
talis, strychnine,  etc.  Atropia  is  only  a  physiological  anti- 
dote ;  there  is  no  known  chemical  antidote  to  muscarin.  The 
poison  in  the  Amanita  phalloides,  the  death  cup,  is  phallin. 
Phallin  is  a  toxalbumin,  and  boiling  fortunately  makes  it  less 
dangerous.  Phallin  kills,  not  by  causing  collapse,  but  by  de- 
stroying the  red  blood-corpuscles,  setting  free  the  haemoglo- 
bin. Poisoning  sets  in  after  from  twelve  to  fifteen  hours. 
The  patient  acts  like  one  in  collapse  of  cholera,  but  death 
comes  not  from  heart  paralysis,  as  in  poisoning  from  the  fly 
amanita,  but  from  the  blood  breaking  down,  causing  exhaus- 
tion. Evacuate  the  stomach  and  treat  on  general  principles. 
Be  sure  and  use  injections  of  normal  salt  solution  into  the 
veins  or  the  tissues.  There  is  no  known  antidote  to  phallin. 
It  is  supposed  to  arrest  the  heart's  action  in  diastole.  The 
proper  treatment  is  to  evacuate  the  stomach  by  proper  meth- 
ods, even  washing  it  out  with  oceans  of  aseptic  warm  water. 
Digitalis  is  probably  antagonistic  to  muscarin.  Give  twenty 
drops  of  tincture  of  digitalis  hypodermically,  and  then  digi- 
talis, whiskey,  ammonia,  and  such  remedies  as  the  case  may 
require.  In  digitalis  poisoning  the  heart  is  usually  arrested 
in  systole. 

Farlow's  rules  for  beginners  gathering  mushrooms  are  as 
follows : 

365 


FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

1.  Avoid  fungi  in  the  button  state,  and  in  the  decayed  state 
if  the  decay  is  only  slight. 

2.  Avoid  all  fungi  which  have  stalks  with  a  swollen  base 
surrounded  by  a  sac-like  or  scaly  envelope,  especially  if  the 
gills  are  white. 

3.  Avoid  fungi  having  a  milky  juice,  unless  the  milk  is 
reddish. 

4.  Avoid  fungi  in  which  the  umbrella  or  pileus  is  thin  in 
proportion  to  the  gills,  and  in  which  the  gills  are  nearly  all 
of  equal  length,  especially  if  the  umbrella  is  bright  colored. 

5.  Avoid  all  tube-bearing  fungi  in  which  the  flesh  changes 
color  when  cut  or  broken  or  where  the  mouths  of  the  tubes 
are  reddish,  and  in  the  case  of  other  tube-bearing  fungi  ex- 
periment with  great  caution. 

6.  Fungi  which  have  a  sort  of  spider-web  or  flocculent 
ring  around  the  upper  part  of  the  stalk  should  in  general  be 
avoided. 

Rules  I,  2,  and  5  may  for  the  beginner  be  regarded  as  abso- 
lute, with  the  exception  to  Rule  2  of  Amanita  ccesarea,  the  gills 
of  which  are  yellow. 

Rules  3,  4,  and  6  have  more  numerous  exceptions,  but 
these  rules  should  be  followed  in  all  cases  unless  the  collector 
is  content  to  experiment  first  with  very  small  quantities, 
and  learn  the  practical  result.  As  to  mushrooms,  they  have 
been  supposed  to  be  highly  nitrogenous  and  hence  strong 
food.  I  have  seen  this  recently  denied,  and  they  were  put 
down  as  wishy-washy  diet.  They  give  up  much  water  on 
cooking. 

The  following  analysis  shows  just  what  they  are  as  food. 
Fresh  mushrooms:  Water,  91.11;  non-nitrogenous  sub- 
stances, 2.57;  fat,  .13;  grape-sugar  mannite,  1.05;  other 
non-nitrogenous  substances,  3.71;  woody  fibre,  .67;  ash, 
-76.  Fresh  truffles:  Water,  72.08;  non-nitrogenous  sub- 
stances, 8.91;  fat,  .62;  other  non-nitrogenous  substances, 
7.54;  woody  fibre,  7.92;  ash,  2.21.  Fresh  common  morel: 
Water,  90;  non-nitrogenous  matter,  3.48;  fat,  .24;  grape- 
sugar  mannite,  .72;   other  non-nitrogenous  substances,  3.95; 

366 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

woody  fibre,  .67;  ash,  .94.  This  is  not  a  strong  showing, 
and  does  not  make  them  the  highly  nitrogenous  diet  we  have 
been  taught  that  they  are.  Remember,  though,  in  cooking 
most  of  the  bulk  goes  off  in  water,  and  what  remains  is  quite 
concentrated. 

There  is  something  unexplained  attaching  to  mushrooms. 
In  Italy  the  common  mushroom,  Agaricus  campestris,  is  not 
only  rejected  as  an  edible  variety,  but  it  is  feared  as  poi- 
sonous. The  climate,  soil,  and  environment  must  make  a 
difference  surely.  The  mushroom  for  spontaneous  reproduc- 
tion probably  depends  on  animals,  especially  the  horse  and 
the  horned  cattle.  The  mycelia  are  taken  in  with  the  grass 
they  eat,  then  passed  through  during  digestion,  and  come  forth 
in  the  manure  of  the  animal.  Animal  droppings  are  the  proper 
material  in  which  to  sprinkle  the  mycelia  when  artificial  culti- 
vation is  to  be  carried  on.  They  grow  in  caves,  in  casks,  or 
in  benches  placed  in  flower  forcing-houses  or  in  cellars.  Some 
grow  them  in  the  cellars  of  dwelling-houses,  where  the  heat- 
ing apparatus  of  the  house  is  utilized  to  give  proper  heat  for 
developing  the  mushrooms  from  the  spores.  This  is  a  very 
dangerous  custom,  as  many  pathogenic  germs  may  be  culti- 
vated at  the  same  time,  and  that  much-dreaded  germ  of  teta- 
nus or  lockjaw,  the  bacillus  tetani,  is  especially  at  home  in 
stable  droppings.  Mushroom  spawn  or  spores  come  in  so- 
called  bricks,  from  their  shape  and  resemblance  to  common 
bricks,  and  can  be  purchased  from  the  general  seed  dealers. 
This  is  really  the  proper  way  to  get  mushrooms.  Raise  or 
buy  the  cultivated  ones.  You  always  then  get  the  common 
mushroom,  a  perfectly  safe  one,  and  the  best  of  all,  taking  all 
things  into  consideration,  and  you  do  not  depend  on  the  Toms, 
Dicks,  and  Harrys  who  gather  the  w'ild  ones  and  hawk  them 
from  door  to  door,  and  who  know  nothing  whatever  about 
discriminate  selection. 

NUTS. 

Nuts  in  the  United  States  are  not  a  staple  article  of  diet. 
and  the  chief  ones  eaten  and  containing  nourishment  are  the 
cocoa-nut,  the  almond,  the  chestnut,  the  English  and  black 

2>^7 


FORTY    YEARS   IN    THE   MEDICAL   PROFESSION 

walnuts,  peanuts,  shellbarks,  and  pecans.  There  are  many  of 
good -flavor  which  are  appetizing  and  attractive,  and  as  one 
lingers  over  a  good  dry  sherry  they  give  a  softness  and  a 
mellowness  to  the  wine  and  bring  out  its  good  qualities,  as  it 
enlivens  and  brightens  the  post-prandial  conversation. 

In  Europe,  especially  in  France  and  Italy,  nuts  enter  largely 
into  the  diet  of  the  poorer  classes.  In  the  United  States,  In- 
dian corn  is  so  plentiful  and  so  cheap,  and  is  so  much  in  every 
way  the  better  food,  there  is  no  need  of  even  the  poorest  of 
our  people  taking  to  nuts  as  food.  Of  late  years  wheat  has 
become  so  reduced  in  price  as  to  make  it  available  for  food 
to  all  of  our  people,  and  the  poorer  classes  are  now  even  turn- 
ing up  their  noses  at  Indian  corn. 

In  France  the  laboring  classes  eat  freely  of  chestnuts. 
They  remove  the  outside  shell  and  blanch  them  by  throwing 
them  into  boiling  hot  water ;  then  rubbing  off  the  inside  skin, 
they  place  a  cloth  wet  with  hot  water  in  an  earthen  pot,  and 
nearly  fill  it  with  chestnuts.  These  they  cover  with  another 
wet  cloth,  and  put  the  pot  on  the  fire  and  steam  them.  They 
usually  eat  them  with  salt,  like  roasted  potatoes,  or  with 
milk.  Thus  eaten,  they  are  a  palatable  and  useful  article  of 
diet.  We  must  remember  that  none  of  the  European  chest- 
nuts are  as  palatable  as  our  American  sweet  chestnuts.  They 
are  much  larger,  but  have  much  less  sugar.  Raw,  they  usu- 
ally are  not  palatable.  In  Europe  they  eat  their  chestnuts 
boiled  and  roasted,  and  in  soups  and  as  dressings  for  meats 
and  poultry.  In  the  mountainous  regions  they  make  a  bread 
out  of  chestnut-meal,  which  is  palatable,  and  they  use  the 
nuts  for  food  for  animals.  For  such  purposes  they  do  not 
shell  them.  In  Europe  they  are  cheap,  selling  for  about  one 
cent  per  pound  at  retail.  Chestnuts  may  be  served  as  a  puree, 
with  chops,  boiled  tongue,  and  such  dishes,  instead  of  mashed 
potatoes,  and  if  made  from  the  American  chestnuts  it  will  be 
found  delightful.  The  marron  glace  is  a  luscious  confection, 
and  is  made  from  the  meal  and  sugar  properly  flavored. 

Chestnut  soup :  Hull  and  blanch  a  pound  of  chestnuts,  the 
best  obtainable ;   put  them  in  cold  water,  then  dry  them,  and 

368 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

cover  them  with  one  quart  of  good  stock;  stew  them  for 
three-quarters  of  an  hour,  then  rulj  them  to  a  paste  and  pass 
them  through  a  fine  wire  sieve;  Ijoil  this  and  add  milk  suffi- 
cient to  make  three  pints  of  soup,  and  season  to  the  taste  with 
salt  and  pepper. 

The  chestnut  botanical ly  is  the  Castanca  vcsca  or  Castanea 
vulgaris.  It  has  an  oblong,  lanceolate  leaf,  serrated  mark- 
edly. The  blossoms  are  peculiar  looking,  and  come  quite  late 
in  the  spring  or  early  summer.  There  are  sterile  clusters  in 
long  catkins,  and  fertile  blossoms,  two  or  three  together,  in 
a  round  prickly  involucre  at  the  base  of  the  catkins.  There 
is  no  corolla.  The  calyx  is  on  the  summit  of  the  ovary,  and 
encloses  the  stamens  and  stigmas.  The  nut  is  familiar  to  all. 
The  chestnut-tree  lives  to  a  great  age,  and  attains  an  enor- 
mous size.  They  analyze  thus  (the  fresh  edible  portion)  : 
Water,  44.9;  protein,  8;  fat,  10.8;  carbohydrates,  54;  ash, 
1.8.  Fuel  value  per  pound,  1480.  Dried:  Water,  5.8;  pro- 
tein, 10.6;  fat,  10;  carbohydrates,  70.9 ;  ash,  2.7.  Fuel  value 
per  pound,  1940.  Here  is  a  food  value  nearly  equal  to  wheat 
flour  or  corn-meal,  and  also  showing  that  the  chestnut  is  not 
fit  food  for  the  diabetic. 

The  chief  enemies  to  the  chestnut  are  the  larvae  of  the 
chestnut  weevils,  the  larger  ones  from  the  Balaniiius  caryatry- 
pcs  and  the  smaller  ones  from  the  Balaniiiiis  rectus.  The 
grubs,  of  a  light  cream-color,  are  often  found  in  the  nuts. 
When  the  trees  are  in  bloom  the  beetle  appears,  just  about 
the  time  the  staminate  catkins  drop.  They  have  long,  slen- 
der snouts,  and  bore  through  the  rough  sticky  burs  and 
through  the  shells  of  the  nuts  within  the  burs.  The  female 
lays  her  eggs  in  the  nut,  and  the  hole  heals.  The  eggs  hatch, 
and  the  larvae  work  within  the  nut  and  mature  with  the  chest- 
nuts. The  w^orm,  now  grown,  eats  through  the  shell  and 
ruins  the  nut.  It  goes  to  the  ground,  where  it  changes  to  a 
pupa,  and  the  next  season  appears  as  a  beetle  again,  and  again 
goes  through  his  transformation.  The  remedies  for  the 
worms  are  not  satisfactory.  Spraying  does  not  reach  them. 
The  best  we  can  do  is  to  kill  those  in  the  gathered  nuts  by 
24  369 


FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

smoke  or  hot  water  and  other  methods,  so  as  to  prevent  the 
larva  from  entering  the  ground  and  changing  into  its  pupa 
state,  and  becoming  a  beetle  again. 

I  ask  no  concessions  for  this  digression  into  this  little  na- 
ture study.  Physicians  should  know  all  about  such  things, 
and  such  studies  are  a  relief  to  one  exhausted  with  the  over- 
work of  practical  medicine.  Physicians,  lawyers,  clergymen, 
school-teachers,  and  others  should  all  take  up  some  form  of 
nature  study.  They  would  be  happier  and  better  in  every 
way.  It  should  in  many  ways  be  taught  in  the  schools,  and 
I  am  glad  to  say  efforts  in  its  behalf  in  that  direction  are  suc- 
ceeding. 

Our  chestnuts  in  this  country  are  the  native  sweet  seedling 
chestnuts,  the  native  grafted  chestnuts,  the  European  chest- 
nuts, and  the  Japan  chestnuts.  Leaf  fungi,  the  Marsonia 
ochroleuca  and  the  Cryptosporium  epiphyllum,  attack  the  Eu- 
ropean and  the  natives,  and  rarely  the  Japan.  Spraying  with 
the  Bordeaux  mixture  used  for  grapes,  etc.,  being  lime  and 
copper  sulphate  in  water,  is  effectual  in  controlling  it. 

Professor  G.  Harold  Powell,  entomologist  and  horticul- 
turist of  the  Delaware  College  Agricultural  Experiment  Sta- 
tion at  Newark,  Delaware,  is  one  of  our  best  authorities  on 
the  chestnut,  as  is  J.  W.  Killen,  of  Felton,  Delaware,  one  of 
our  best  practical  authorities.  Powell  holds  that  the  Japan 
flora  better  suits  the  United  States  than  the  flora  of  the  chest- 
nuts from  Western  Europe,  and  thinks  the  Japans  will  im- 
prove greatly  by  selection,  etc.,  in  our  country,  and  also  by 
the  infusion  into  them  of  our  native  stock. 

To  my  own  taste  our  native  chestnut  and  our  native  chin- 
quapin, Castanea  pumila,  are  by  far  the  best  of  all  in  flavor, 
whether  raw  or  cooked.  Next  come  the  European  varieties 
native  in  the  United  States,  as  the  Ridgely,  Paragon,  Numbo, 
and  the  du  Pont.  Next  come  the  Japans  grafted,  which  are 
■dwarfish  in  their  nature  and  very  early  and  prolific  bearers. 
The  best  of  them  are  Kerr,  Martin,  Biddle,  Doctor  Black  (for 
an  early  one),  Kent,  Killen,  Hale,  and  Parry.  Last  I  place 
the  European  seedlings,  generally  known  as  Italian  chestnuts 

370 


FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

with  us.  I  have  a  number  of  trees  a  quarter  of  a  century  old, 
which  bear  large  crops.  The  weevil  is  hard  on  them.  Most 
of  my  trees  fortunately  bear  good  large  nuts,  but  in  buying 
these  seedling  trees,  of  course  it  is  a  lottery  as  to  what  quality 
of  nut  you  get.  The  leaves  of  the  chestnut  have  antispas- 
modic properties,  and  the  fluid  extract  is  a  remedy  in  per- 
tussis and  such  troubles. 

Peanut. — The  peanut  is  a  legume,  the  Arachis  hypogcoa. 
The  French  call  it  the  pistache  dc  terrc.  It  comes  to  us  either 
from  Africa  or  Brazil.  Its  chemical  composition  is :  Edible 
portion,  water,  9.2;  protein,  25.8;  fat,  38.6;  carbohydrates, 
24.4;  ash,  2.  Fuel  value  per  pound,  2560.  Here  is  a  very 
strong  food,  high  in  protein  and  fat  particularly,  and  too 
strong  in  carbohydrates  for  diabetics.  It  is  the  poor  man's 
nut  for  food  beyond  all  others.  They  are  too  strong  in  fat 
for  many  stomachs,  but  a  little  fruit  or  subacid  jams  eaten 
after  them  will  help  out  in  their  digestion  by  assisting  to  emul- 
sify the  peanut  oil.  Vast  quantities  of  these  nuts  are  raised 
in  the  United  States,  and  they  are  of  very  great  commercial 
importance,  furnishing  a  staple  article  of  diet  in  the  nuts,  and 
much  oil  useful  for  many  purposes,  even  making  a  very  good 
salad  oil,  and  with  our  cotton-seed  oil  often  sold  for  the  best 
olive  oil. 

Almonds — Amygdalus. — The  plum,  peach,  cherry,  and 
nectarine  are  of  the  same  genus.  The  peach  is  the  Amygda- 
lus persica.  There  are  the  bitter  and  sw'eet  almonds.  The 
bitter  almond  has  less  oil  than  the  sweet,  but  contains  more 
hydrocyanic  acid.  The  leaves  of  both  contain  much  hydro- 
cyanic acid.  The  sweet  almond  is  a  toothsome  nut,  but  in- 
digestible, as  a  rule.  Sweet  almond  oil  is  much  used,  and 
valuable  in  its  way.  The  chemical  analysis  of  sweet  almonds 
is  as  follows:  Water,  6;  protein,  23.5;  fat,  53;  carbohy- 
drates, 14.3;  ash,  3.1.  A  gouty  and  fat- forming  food,  it 
should  be  used  only  moderately,  to  bring  out  the  flavor  of 
sherry,  Madeira,  or  port. 

Filberts  or  Hazel  Nuts. — Genus,  Corylus.  Two  species 
are  native  of  the  United  States.     They  flower  very  early  in 


FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

the  spring  and  are  attractive.  They  are  bushes  rather  than 
trees.  ■  The  Corylus  colurna  grows  to  a  tree  in  Asia,  and  yields 
a  fine  oil.  The  chemical  analysis  is  as  follows:  Water,  7.1; 
protein,  17.4;  fat,  62.6;  carbohydrates,  10.4;  ash,  2.5.  Like 
almonds,  they  are  low  in  carbohydrates  and  high  in  fat.  Dia- 
betics may  eat  them  moderately,  as  they  may  eat  almonds. 

Pecans. — The  Carya  olivcBformis,  or  hicoria  pecan,  is  a 
species  of  hickory.  This  nut  is  very  common  in  the  South, 
and  especially  in  the  Southwestern  United  States.  It  thrives 
in  the  Middle  States,  especially  on  the  Delaware  and  Chesa- 
peake Peninsula.  It  has  been  proposed  to  graft  it  on  the 
English  walnut  to  hurry  its  growth  and  to  improve  the  nuts. 
It  will  take  on  all  of  the  hickories.  Dr.  John  Le  Conte,  of 
Philadelphia,  well  known  for  his  scientific  attainments, 
brought,  in  1853,  a  unique  pecan  from  Texas.  He  named 
it  Hicoria  tcxana.  It  has  been  cultivated  in  Georgia.  The 
tree  only  attains  a  height  of  from  ten  to  twelve  feet.  The 
ordinary  pecan-tree  grows  to  a  height  of  one  hundred  feet. 
Pecans  are  becoming  very  plentiful,  as  large  orchards  of  them 
are  being  planted  commercially  in  different  parts  of  the  coun- 
try. They  analyze  not  much  differently  from  the  filbert  or 
shellbark,  or  the  common  hickories.  The  membrane  covering 
the  kernel  is  bitter,  and  should  be  avoided  in  eating  them. 
They  are  high  in  oil.  The  kernel  will  burn  and  make  a  good 
light.  Pounded  up  or  ground,  shells  and  all,  they  make  good 
hog-feed.  Corsa  thinks  the  mast  fed  to  cows  would  give  a 
good  flavor  to  butter  if  the  shell  were  excluded. 

Shellbark  or  Shagbark. — William  P.  Corsa  gives  this 
as  Hicoria  laciniosa  (Sargent)  or  Carya  sulcata  (Nuttall). 
This  is  undoubtedly  the  best  flavored  of  all  the  nuts  that 
grow.  The  best  are  so  soft  of  shell  that  they  may  be  cracked 
with  the  teeth,  although  I  am  free  to  admit  that  an  inorganic 
nut-cracker  or  hammer  of  some  kind  would  be  safer  so  far  as 
the  teeth  are  concerned.  The  nut  is  oily,  fairly  high  in  pro- 
tein, and  sufficiently  low  in  carbohydrates  for  the  diabetic  to 
eat.  There  are  many  other  species  of  the  hickory-nut,  all  of 
which  have  been  noted  by  Corsa  in  his  work  on  Nuts  and 

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FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

Nut  Culture  in  the  United  States.  There  arc  the  Mocker 
Nut,  Hicoria  alba,  known  as  the  bull  nut,  etc. ;  the  Pignut, 
Hicoria  glabra,  or  Bitter  Hickory;  the  Nutmeg  Hickory, 
Hicoria  myristiccofornis;  the  Bitter  Nut,  Hicoria  minima; 
the  Water  Hickory,  Hicoria  aquatica. 

Cream  Nut,  Brazil  Nut — Bertholletia  Excelsa. — It  be- 
longs to  the  order  Lectythidacca.  The  natives  call  it  Juvia. 
It  is  too  tender  as  to  frost  for  the  United  States,  even  for 
Southern  Florida,  commercially.  This  nut  is  a  curiosity. 
They  are,  as  we  see  them  in  the  stores,  in  the  form  of  a  trian- 
gular prism;  a  number  of  these  are  contained  in  a  round 
case  or  box,  fitted  in,  the  case  being  often  as  large  as  a  child's 
head.  Crack  the  case,  and  out  fall  the  nuts.  The  meat  is  in 
one  piece,  like  an  almond,  and  of  the  triangular  shape  of  the 
hull.  When  fresh  they  have  a  fine  flavor.  As  they  grow  old 
they  become  rancid.  In  this  country  we  do  not  often  get 
good  fresh  Brazil  nuts.  The  oil  from  the  nuts  makes  good 
lamp  oil. 

Chilean  Nut. — A  most  beautiful  tree,  and  is  growing 
successfully  in  California,  Guevina  avellana.  The  fruit  has 
an  agreeable  nut-like  taste,  but  in  its  raw  state  is  poisonous, 
like  the  Brabejum. 

Queensland  Nut — Macadamia  Ternifolia. — Corsa  re- 
ports this  fruit  like  a  drupe,  round  and  smooth,  with  a  shell 
like  a  walnut ;  it  is  like  the  filbert,  but  superior  in  flavor. 

Betel  Nut — Arcca  Catechu. — This  is  only  one  of  the  areca 
nuts.  The  fruit  is  the  size  of  a  hen's  tgg,  and  the  seed  or 
nut  is  the  size  of  a  nutmeg.  The  people  of  India  chew  it  as 
the  Americans  chew  tobacco,  calling  it  betel.  This  is  made  by 
mixing  it  with  the  leaves  of  the  piper  betel  and  lime.  The  nut 
is  used  mostly  with  us  by  reducing  it  to  charcoal  and  then 
making  a  tooth-powder  from  it.  This  charcoal  is  so  hard  it 
pohshes  the  enamel  of  the  teeth.  From  four  to  six  drachms 
of  the  nut  is  said  to  be  effectual  in  tapeworm.  One  of  the 
various  catechus  comes  from  the  Arcca  catechu,  official  U.S. P. 

Pistachio  Nut — Pistach — Pistacia  Vera. — The  tree  is 
dioecious.     The  nuts  are  borne  on  the  female  tree  in  clusters. 


FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

and  are  covered  with  a  light-green  husk.  The  tree  is  a  native 
of  Syria,  but  has  been  introduced  into  the  United  States  and 
grows  successfully  in  the  South  and  in  California.  It  is 
used  for  flavoring  medicines  and  confectionery,  and  also  for 
coloring  them  light  green.  The  French  use  it  to  flavor  sau- 
sages and  such  foods. 

Kola  Nut — Sterculia  Acuminata,  Cola  Acuminata. — This 
nut  is  a  native  of  Africa.  It  commences  to  bear  when  four 
years  old.  The  tree,  like  the  orange,  has  the  flowers  and 
fruit  on  it  at  the  same  time.  The  ripe  nut  is  a  brownish 
yellow  capsule,  inclosing  both  red  and  white  seed,  varying  in 
number  from  five  to  twenty.  They  are  collected  and  assorted 
with  care.  The  sound  seeds  are  placed  in  dark  baskets  lined 
with  leaves,  and  are  thus  transported.  If  not  well  cared  for, 
they  are  liable  to  ferment.  According  to  Dr.  Neish,  the  nut 
is  rich  in  caffeine  and  theobromine.  Kola  nuts  contain  more 
caffeine  than  coffee,  and  in  them  it  is  free  and  uncombined 
and  easy  to  obtain  pure.  It  lessens  mental  and  bodily  fatigue, 
and  is  safer  than  beer  as  a  beverage.  The  natives  of  Africa 
esteem  it  highly  as  a  help  in  fatigue.  It  may  be  harmless,  but 
surely  all  such  remedies  need  care  and  watching  in  pre- 
scribing, and  kola  and  coca  are  among  those  needing  most 
to  be  watched. 

GuARANA. — The  fruit  and  leaves  of  the  Paullinia  sorbilis; 
these  also  furnish  caffeine,  and  also  are  astringent. 

Butternut — Juglans  Cinerea — White  Walnut. — This 
nut  is  very  generally  distributed  in  the  United  States.  In 
Delaware  it  is  common  along  the  banks  of  the  White  Clay 
Creek.  The  soft  half-grown  nuts  make  a  very  good  pickle. 
The  quality  of  the  nut  is  put  down  as  good.  Personally,  I 
do  not  like  it.  It  is  difficult  to  remove  from  the  shell,  and  is 
strong  in  oil. 

Black  Walnut — Juglans  Nigra. — Every  one  knows  this 
nut,  it  is  so  widely  distributed.  It  is  more  planted  for 
its  timber  than  for  its  nuts.  It  bears  a  strong  oily  nut,  but 
has  a  flavor  of  its  own.  Its  analysis  is  as  follows :  Water, 
2.5;  protein,  24.9;   fat,  54.7;   carbohydrates,  16.3;   ash,  1.7. 

374 


FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

It  is  quite  a  strong  food,  very  oily,  with  a  little  too  much  car- 
bohydrates for  diabetics  to  eat  of  freely.  A  few  will  do  them 
no  harm.  My  friend.  Dr.  Robert  P.  Harris,  of  Philadelphia, 
recently  deceased,  has  called  my  attention  to  the  effect  of 
washing  with  soap  and  water  a  black  walnut  just  taken  from 
its  green  hull.  It  makes  it  of  a  beautiful  light  cream-color, 
and  renders  it  quite  attractive  for  market. 

California  Walnut — Juglans  Californica. — This  is  a 
California  black  walnut.  Its  fruit  is  smaller  than  the  Eastern 
walnut.  It  makes  a  good  stock  for  the  Persian  walnut.  Ju- 
glans rupestris  is  another  black  walnut  common  to  Texas. 

English  Walnut,  Madeira  Nut,  Persian  Walnut, 
Grenoble  Walnut — Juglans  Regia. — This  tree  is  a  native 
of  Asia.  It  is  widely  distributed.  It  grows  in  Delaware  to 
perfection,  and  I  have  never  seen  it  cut  down  by  frost.  It 
bears  abundantly.  The  anguillula  does  not  affect  it  here.  In 
the  city  of  New  Castle  there  are  trees  probably  a  century  old, 
which  bear  bushels  of  the  best  nuts  annually.  The  houses 
screen  them  and  doubtless  prevent  sun  scald.  In  exposed 
places  this  can  be  prevented  by  screens.  I  have  fine  thrifty 
trees  growing  on  my  fruit  farms  in  Delaware  and  Maryland 
over  twenty-five  years  old.  As  yet  they  have  borne  few  nuts. 
In  my  experience  the  tree  does  not  commence  to  bear  in  or- 
chard culture  in  the  Middle  States  under  sixteen  to  twenty 
years  of  age.  The  chemical  analysis  is  as  follows :  Water, 
2.5;  protein,  17.1;  fat,  60;  carbohydrates,  19.1;  ash,  1.4. 
They  are  quite  rich  in  fat,  and  almost  too  strong  in  carbohy- 
drates for  diabetics  to  eat  freely.  There  are  many  varieties, 
with  no  great  difference  between  them,  some  having  softer 
shells  than  others.  The  finest  seedling  I  have  seen  was  from 
a  tree  in  Merchantville,  New  Jersey,  and  sent  to  me  by  the 
late  Dr.  Robert  P.  Harris. 

Japan  Walnut — Juglans  Sieholdiana,  Juglans  Cordifor- 
mis,  Juglans  Mandshurica. — The  Mandshurica  is  much  like 
our  butternut,  but  has  a  very  much  harder  shell.  The  meat 
is  a  little  on  the  butternut  flavor.  The  Sieboldiana  does  not 
differ  much  from  the  Mandshurica;   probably  the  shell  is  a 

375 


FORTY    YEARS    IN   THE    MEDICAL    PROFESSION 

little  more  like  the  English  walnut  shell,  but  very  much 
harder;  indeed,  it  is  very  hard  and  dense.  Cordiformis  is 
smaller  than  the  other  two,  and  has  a  somewhat  softer  shell. 
The  trees  all  look  alike.  The  nut  may  be  a  valuable  addition 
to  our  list,  but  as  a  shade-tree  I  regard  the  Japan  walnut  as 
a  very  great  addition  and  a  great  boon.  The  trees  have  beau- 
tiful foliage,  beautiful  blossoms  at  the  tips  of  the  branches, 
bear  their  fruit  in  clusters,  and  grow  more  rapidly  than  the 
Carolina  poplar;  in  fact,  they  are  hardier,  and  will  produce 
good  effect  and  good  shade  quicker  than  any  other  tree  I 
know  of.  The  Persian  walnut  is  also  a  beautiful  lawn  tree, 
and  grows  fairly  rapidly.  The  Eucalyptus  globulus  grows  as 
fast  as  the  Japan  walnut,  but  is  not  hardy  generally  in  the 
United  States,  and  absorbs  so  much  water  that  it  robs  other 
trees  and  plants  near  it. 

SouARi  Nut. — This  is  a  new  nut  just  introduced  into  this 
country  from  the  Indian  River  country  of  Venezuela.  This 
nut  consists  of  a  single  nut  in  a  very  hard  shell,  like  the  Brazil 
nut,  except  that  the  Brazil  nut  is  multiple  in  its  larger  shell, 
not  single.  The  outer  shell  of  the  souari  nut  is  very  hard, 
and  is  clam-shaped  and  of  a  snuff-color.  It  has  a  creamy 
taste,  but  is  inferior  to  the  Brazil  nut  in  flavor.  It  has  some- 
thing of  a  raw  mushroom  odor  and  flavor.  It  may  be  eaten 
plain,  or  with  pepper  and  salt,  or  with  cheese,  or  may  be 
roasted  or  boiled. 


v^J 


CHAPTER    XL 

George  B.  Wood  and  S.  D.  Gross  on  Tubercle — Koch's  Discovery  of  the 
Bacillus  TuI)erculosis — Present  Definition  of  Tubercle — Physical  Attri- 
butes of  Tubercle — Tubercle  Bacillus  in  Man  and  the  Lower  Animals — 
Pulmonary  Tuberculosis  in  Man — The  Physician  and  Tuberculosis — 
Early  Diagnosis  Important — The  Bacillus  and  Diagnosis — Case  of 
Chronic  Interstitial  Pneumonia  and  Tuberculocidin — Tuberculins  and 
their  Therapeutic  Principles  and  Uses — Toxines  and  Antitoxins — 
Koch's  Tuberculins  A,  O,  and  R — Maragliano's  Serum — Virchow's  Ob- 
jections to  Koch's  Tuberculin  A — Mulford's  Serum — The  Economics  of 
Tuberculin — Tuberculous  Cattle  in  Europe  and  America — Necessity  for 
Action — Prevention  and  Treatment  of  Tuberculosis — Surgical  Tubercu- 
losis— Treatment  of  Haemoptysis — Murphy's  Method  of  treating  Pul- 
monary Tuberculosis  —  Secondary  Infection  —  Cures  —  What  Factors 
hold  Tuberculosis  Latent  —  Climate  and  Environment  —  Pulmonary 
Hemorrhage  and  Altitude  —  The  Indians  as  an  Object-Lesson  —  Re- 
lieving Crov^'ded  Centres — Sanitaria  and  Sanatoria  and  Treatment — 
Common  Colds — Consumption  in  Hotels — Solitary  Life  Best — Altitude 
— The  Heart  and  Altitude — Diabetics  and  Altitude — The  Climate  of  the 
United  States  East  and  West — Sanatoria  and  Climate  in  Europe — 
Serum  Treatment  in  the  Adirondacks — Inhalations  as  Remedies. 

Without  discussing-  its  cause  at  the  opening  of  this  chap- 
ter, we  may  well  say  that  tuberculosis  is  the  greatest  of  all 
factors  in  hurrying  mankind  to  death;  not  only  mankind, 
but  the  lower  animals  as  well,  descending  to  as  yet  unknown 
depths  in  the  scale  of  life,  and  carrying  destruction  to  an  ex- 
tent that  we  are  only  just  beginning  to  realize  and  under- 
stand. Forty  years  ago  Professor  George  B.  \\^ood  was  a 
close  observer  and  a  high  authority  on  medical  subjects.  His 
distinction  between  tubercle  and  cancer  was  that  tubercle 
tended  to  health,  and  cancer  tended  to  death.  His  definition 
of  tubercle  was :  A  solid  extravasated  matter,  which,  in  cer- 
tain states  of  the  system,  is  deposited  in  various  parts  of  the 
body,  and  from  its  shape,  ordinarily  assumed,  is  called  tu- 
bercle.    The  state  of  the  system  leading  to  this  deposit  was 

Z77 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

called  in  those  days,  as  it  is  to-day,  the  tuberculous  diathesis. 
He  recognized  the  gray  and  translucent  and  the  yellow  and 
opaque  tubercles,  that  they  underwent  softening,  acted  as 
foreign  bodies,  and  sometimes  the  cavities  left  by  them  healed, 
or  the  whole  mass  became  protected  by  organized  fibrin  and 
isolated  from  doing  harm.  He  recognized  heredity  as  a 
cause  of  tuberculosis.  To  his  idea,  tubercles  were  not  a 
product  of  inflammation,  but  were  a  cause  themselves  of  in- 
flammation. At  this  time  they  were  cutting  quite  close  to 
the  cause  of  tubercle,  or  rather  tuberculosis,  by  microscopic 
investigation,  and  the  one  thing  lacking  was  the  advent  of 
some  genius  to  add  staining  of  the  specimens  to  the  resources 
of  the  microscopist. 

Compound  corpuscles  were  noticed  by  Virchow  as  early 
as  1 85 1.  Pus  was  not  inherent  in  tuberculous  masses,  but, 
when  present,  came  from  the  surrounding  inflamed  tissues. 
As  tubercle  softened,  fatty  matter  was  generated,  and  a  fatty 
degeneration  took  place.  The  true  tuberculous  liquid  was 
sometimes  absorbed,  and  left  in  the  place  of  the  tubercle  only 
a  calcareous  mass.    That  is  a  physical  fact  true  to-day. 

To  sum  up,  here  is  Wood's  definition  of  tubercle,  and  the 
accepted  definition  among  a  great  majority  of  pathologists 
of  that  day :  A  formless  fibrinous  matter  is  first  extravasated, 
having  a  low  and  feeble  vitality;  that,  as  the  result  of  an 
imperfect  attempt  at  organization,  coagulation  takes  place 
with  the  production  of  granules  and  peculiar  corpuscles,  and 
that  the  tubercle  thus  formed  grows  by  accretion  of  similar 
matter  to  its  surface,  and  then,  as  a  result  of  the  law  of  its 
constitution,  undergoes  a  series  of  changes,  ending  in  its 
complete  disintegration.  Light  at  this  time  was  just  com- 
mencing to  dawn  upon  the  profession  as  to  the  zymotic  nature 
of  so  many  diseases.  Two  theories  as  to  contagion  were  then 
in  vogue,  and  advanced  thinkers  were  becoming  less  and  less 
conservative.  The  first  theory  of  contagion  was  fermenta- 
tive, the  ferments  entering  the  blood  and  causing  chemical 
changes  that  result  in  a  further  production  of  similar  conta- 
gious matter.     Thus  the  reproduction  of  the  morbific  agent 

37S 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

is  explained.  The  contagions  existing  in  the  system  are  ex- 
hausted by  these  fermentations,  and  thus  second  attacks  of 
such  diseases  are  prevented. 

The  second  explanation  of  contagion  is  on  the  germ  theory, 
"  invisible  organic  agents,  animal  or  vegetable,  which,  fully 
developed  or  in  the  state  of  germs,  enter  the  blood-vessels 
and  there  live  and  propagate  to  the  no  little  disturbance  of 
the  system,  which  is  at  length  excited  into  desperate  efforts 
and  throws  off  the  intruders  and  their  whole  brood,  or  per- 
ishes in  the  attempt."  This  doctrine  was  not  exactly  accepted 
by  Wood  and  his  contemporaries,  but  they  were  beginning  to 
see  visions  of  the  true  causes  of  disease. 

In  1864  Professor  S.  D.  Gross  made  no  distinction  between 
tuberculosis  and  scrofula.  To  him  phthisis  and  scrofula  were 
the  same.  A  tubercle  in  the  lung  was  the  same  disease  as  a 
tubercle  in  a  bone  or  in  a  lymphatic  gland^  having  the  same 
origin,  running  the  same  course,  and  producing  the  same 
results.  He  intimated  that  he  considered  syphilis  as  the  great 
parent  of  tubercle  and  its  parasitic  existence.  The  old  gentle- 
man had  a  way  about  him  of  looking  ahead,  and  getting  about 
as  near  the  truth  without  the  use  of  modern  helps  as  any  of 
his  contemporaries.  He  denied  that  tubercle  was  an  unor- 
ganizable  product  like  colloid  and  melanosis.  Gross  was  one 
of  the  best  pathologists  of  his  day.  The  blood-vessels  demon- 
strated to  be  in  it  clearly  show  there  is  something  \vithin  it 
to  be  nourished  and  protected.  Tubercle  is  an  organic  sub- 
stance, he  repeats,  because  it  often  begins  to  soften  at  its 
centre.  He  looked  upon  tubercle  as  a  morbid  deposit  pro- 
voked by  anything  causing  the  system  to  run  down,  from 
heredity  to  syphilis.  Local  inflammation  of  the  part  sets  the 
seat  of  the  tuberculous  deposit.  Gross  denied  the  contagious- 
ness of  scrofula  or  tuberculosis. 

Less  than  twenty  years  ago  these  vie\vs  of  forty  years  ago 
which  I  have  quoted  were  held  and  defended  by  the  average 
pathologists  and  thinking  men  of  the  medical  profession,  and 
it  was  only  as  far  back  as  1881  that  Robert  Koch  gave  to  the 
scientific  world  his  famous  and  far-reaching  discovery  of  the 

379 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Bacillus  tuberculosis,  and  demonstrated  it  beyond  peradven- 
ture.  to  be  the  cause  of  all  forms  of  tuberculosis,  thus  clearing 
up  many  questions  which  had  been  clouded  by  the  mists  of 
ages,  and  giving  to  suffering  man  a  scientific  basis  upon  which 
to  work  and,  I  trust,  to  effectually  eliminate  the  greatest 
enemy  to  his  future  existence  and  continued  happiness.  Since 
Koch's  discovery  we  know  enough  to  define  tuberculosis  as  an 
infectious  disease,  the  cause  of  the  infection  to  be  the  bacillus 
tuberculosis.  We  know  now  the  cause  of  the  tubercles  to  be 
the  setting  up  of  a  specific  inflammation  by  the  tubercle  bacilli, 
and  the  cause  of  general  tuberculosis  to  be  the  same  micro- 
organism. We  know  the  end  of  these  inflammations  may  be 
caseation  or  hardening,  and  these  may  end  in  ulceration, 
chronic  ulcerative  consumption,  or  calcareous  degeneration, 
which  is  a  method  of  cure,  the  calcareous  masses  being  ex- 
pectorated or  remain  in  the  lungs,  surrounded  by  a  ring  of 
hyperplastic  connective  tissue.  As  to  the  tubercle  bacillus, 
this  is  not  the  place  to  discuss  it,  for  it  is  as  well  known  to 
bacteriologists  as  the  cattle  are  to  farmers. 

There  is  one  question  yet  probably  not  clearly  settled.  Is 
the  bacillus  tuberculosis  of  man  identically  the  same  as  the 
tubercle  bacillus  of  the  lower  animals?  As  to  the  onset  of 
pulmonary  tuberculosis  particularly,  I  propose  to  give  the 
result  merely  of  my  own  personal  experience.  If  the  practice 
of  medicine  was  properly  appreciated  by  the  world,  and  was 
not,  even  at  this  enlightened  era  of  its  existence,  looked 
upon  by  the  average  man  as  a  mere  business  of  pill-giving, 
empirically  at  that,  the  family  physician  in  his  watching  over 
his  clients,  if  he  were  an  intelligent  and  careful  man,  would 
probably  see,  on  account  of  his  training,  some  youthful  mem- 
ber of  the  family,  not  sick,  yet  not  well.  A  close  scrutiny  of 
the  individual,  having  gone  over  the  family  history,  which  he 
would  know  anyhow,  for  that  would  be  a  part  of  his  business, 
would  show  that  probably  after  three  o'clock  p.m.  almost 
daily  the  bodily  temperature  of  his  ward  would  be  one  or  two 
degrees  above  normal,  and  the  cheeks  would  flush  slightly; 
and  further  investigation  would  show  at  this  time  that  there 

380 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

was  a  slight  fulness  at  the  top  of  the  sternum  and  a  tendency 
to  hack  a  little;  all  these  symptoms  passing  off  with  a  slight 
moisture  of  the  skin  and  a  little  debilitated  feeling  towards 
midnight.  To  the  practised  car  some  change  in  the  physical 
signs  in  the  lungs  would  be  found,  if  in  a  space  never  so  small, 
and  possibly,  by  proper  examination,  the  dreaded  micro- 
organism of  consumption  would  be  found  in  the  sputum. 
The  diagnosis  thus  early  assured,  what  innumerable  chances 
of  recovery  that  patient  would  have  over  those  coming  for 
help  late  with  the  disease  well  established.  Should  no  trouble 
be  found  in  the  lungs,  it  would  be  the  duty  of  the  physician 
to  institute  a  thorough  examination  of  every  part  and  organ 
of  the  body  where  tubercle  might  invade,  and  weigh  all  the 
symptoms. 

See  the  other  side  of  the  picture :  a  happy  family,  with  no 
medical  supervision,  with  a  bad  family  history  as  to  tuber- 
culosis, if  you  choose;  a  favorite  son  or  daughter  just  bud- 
ding into  maturity,  all  these  symptoms  appearing  as  enumer- 
ated :  the  high  evening  temperature, — oh,  only  the  crimson 
cheek  of  health;  the  cough, — only  a  little  cold;  the  pro- 
gressive weakness — nothing,  the  appetite  is  so  good,  only  a 
little  rest  required ;  and  so  the  case  goes  on, — cough,  sweats, 
expectoration,  hemorrhage  perhaps,  and  then  the  doctor  called 
in  haste.  An  examination  shows  the  helplessness  of  all 
human  aid,  and  another  is  added  to  the  death-rate  of  con- 
sumption, already  appalling,  and  much  of  this  owing  to  faulty 
methods  in  the  organization  of  society.  The  only  remedy  for 
this  state  of  affairs  is  for  society  to  recognize  the  necessity  of 
constant  medical  supervision  over  each  and  all  of  its  mem- 
bers.   To-day  it  clings  to  the  old  couplet  philosophy : 

When  the  devil  was  sick,  the  devil  a  monk  would  be ; 
When  the  devil  was  well,  the  devil  a  monk  was  he. 

Moral :  The  devil  does  not  know  when  lie  is  sick,  but  should 
have  an  expert  at  hand  to  tell  him.  The  chances  of  cure  in 
consumption,  or  of  checking  its  progress,  all  depend  upon  an 
early  diagnosis.    I  think  this  is  a  law,  surely;   that  it  is  the 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

experience  of  every  thoughtful  practitioner  of  medicine,   I 
doubt  not. 

The  finding  of  the  bacillus  tuberculosis  in  the  sputa  con- 
firms the  diagnosis  of  pulmonary  consumption.  Does  the 
failure  to  find  it  declare  the  case  not  to  be  one  of  pulmonary 
consumption?  I  must  confess  that  in  my  experience  it  ex- 
cludes it.  I  have  had  some  most  interesting  cases,  and  where 
the  bacillus  was  not  found  they  all  came  out  right.  I  had 
one  most  remarkable  case :  this  man  had  all  the  rational  signs 
of  consumption;  for  a  year  his  cough  disturbed  the  neigh- 
borhood, his  expectoration  was  profuse,  his  emaciation  ex- 
treme, and  with  his  coughing  spells  he  vomited  his  food.  He 
had  evening  rise  of  temperature,  and  it  was  never  normal, 
and  hectic  and  night  sweats  were  marked.  In  this  condition 
he  came  to  me.  He  had  numerous  moist  bronchial  rales  with 
puerile  respiration,  except  in  the  lower  lobe  of  the  left  lung, 
which  was  flat.  The  apices,  with  the  exception  of  the  respi- 
ration, were  normal.  His  family  history  was  not  first  class. 
There  was  no  fluid  in  the  pleural  cavities ;  there  was  dyspnoea, 
the  chest  was  retracted,  its  circumference  was  diminished,  and 
its  movements  were  restricted ;  there  was  even  amphoric  res- 
onance over  the  diseased  lung.  The  man  was  the  picture  of 
a  case  in  the  last  stages  of  consumption,  with  secondary  infec- 
tion of  the  system;  and  such  was  my  fear,  although  there 
were  some  hopeful  signs,  as  sound  apices,  etc.,  left  to  comfort 
me.  I  am  never  willing  to  give  an  opinion,  even  in  such  a 
case,  until  after  one  or  more  examinations  of  the  sputa.  I  felt 
sure  those  of  this  man  were  reeking  with  the  micro-organism. 
Repeated  examinations  by  one  of  the  ablest  bacteriologists 
in  this  country.  Professor  F.  D.  Chester,  of  the  Delaware 
College  Agricultural  Experiment  Station  and  the  Delaware 
State  Bacteriological  Station  at  Newark,  Delaware,  failed  to 
find  a  single  specimen.  I  began  to  have  hope  that  the  man 
would  get  well,  but  it  seemed  like  hoping  against  hope.  With 
bacteriological  examinations  frequently,  the  man  went  on  for 
months  without  much  improvement,  although  everything  ap- 
parently possible  was  done  for  him. 

382 


FORTY    YEARS   IN   THE   MEDICAL    PROFESSION 

After  these  repeated  investigations  for  the  bacillus  tuber- 
culosis, with  nej2^ative  results,  I  made  the  diagnosis  of  chronic 
interstitial  pneumonia,  with  a  possil^le  chance  of  improvement, 
but  not  of  cure.  I  then  commenced  the  use  of  tubercu- 
locidin,  which  came  from  Germany,  and  which  I  obtained 
through  the  courtesy  of  Dr.  Arthur  T.  Neale,  Director  of  the 
Delaware  Experiment  Station.  The  result  was  wonderful. 
The  other  treatment  was  kept  up.  Normal  vesicular  murmur 
gradually  appeared  in  the  diseased  lung,  and  the  man,  from 
having  given  up,  began  to  regain  his  spirits.  In  six  months 
he  was  apparently  well,  went  into  business,  and  now  for  sev- 
eral years  has  been  an  active,  successful  citizen,  and  keeps  up 
with  the  boys,  too.  The  tuberculocidin,  I  believe,  had  some 
effect.  There  was  reaction  after  each  injection  at  first,  and 
he  had  a  great  number,  extending  over  months.  It  must 
have  had  some  effect  on  the  fibrous  structure,  and  allowed  the 
restoration  of  the  alveolar  structure  of  the  lung. 

Klebs  prepared  tuberculocidin  by  separating  it  from  the 
original  tuberculin  by  chemical  reagents.  It  is  supposed  to 
contain  germicidal  agents  specific  to  the  pathogenic  organ- 
ism, which  germicidal  agents  are  produced  by  the  pathogenic 
organism  in  the  culture  medium.  The  books  give  chronic 
interstitial  pneumonia  as  a  lingering,  but  incurable  disease. 
Since  this  case,  I  have  had  no  case  in  which  to  repeat  the 
treatment.  Should  I  get  a  similar  one,  I  should  use  tubercu- 
locidin, or  one  of  the  tuberculins.  If  my  diagnosis  was  cor- 
rect, and  I  think  it  was,  this  case  surely  got  well.  As  to  the 
tuberculins  and  kindred  products,  I  have  used  them  all  or 
most  of  them,  or  seen  the  result  of  their  use  in  conjunction 
with  medical  friends.  I  do  not  like  to  give  up  hope  for  the 
hopeless  in  this  direction,  but  oh,  what  a  cruel  fate  was  that 
which  dashed  the  hopes  first  held  out  to  these  poor  sufferers 
by  Koch's  first  eft'orts!  I  hope  still,  even  if  it  is  against  the 
laws  of  true  science  as  we  see  them  to-day,  to  look  for  hope 
and  relief  in  this  direction.  I  brush  aside  all  such  doubts, 
and  still  I  hope,  and  hope,  and  hope,  and  trust,  and  trust,  and 
trust,  and  to-day  I  almost  believe  succor  will  at  last  come 

383 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

from  some  such  source,  for  do  we  not  know  that  in  nature 
every  Hving  thing  generates  its  own  poison,  why  not  this  king 
of  httle  microbes  ? 

Professor  Samuel  O.  L.  Potter,  of  San  Francisco,  the  well- 
known  author,  has  given  us  clear  views  as  to  the  different 
tuberculins  and  what  they  are.  He  says,  in  strict  usage  the 
term  serum  therapy  would  include  only  the  employment  of 
blood-serum  from  an  animal  other  than  the  patient,  the  serum 
carrying  an  antitoxin  specific  to  the  disease  from  which  the 
patient  may  be  suffering.  As  generally  used,  it  embraces  also 
the  use  of  toxines  and  modified  toxines,  produced  in  media 
other  than  the  blood-serum.  The  therapeutic  principle  is  the 
same  in  all, — the  employment  of  an  agent  produced  by  the 
life  action  of  a  pathogenic  organism  for  the  purpose  of  effect- 
ing an  artificial  immunity  against  the  disease  to  which  the 
said  organism  is  specific.  If  we  use  a  toxine,  the  organic  cells 
of  the  patient's  body  are  supposed  to  be  excited  to  produce  an 
antitoxin  in  the  patient's  own  blood-serum.  If  we  use  an 
antitoxin,  the  organic  cells  of  another  animal  are  relied  upon 
for  the  manufacture  of  the  antitoxin,  the  patient  being  saved 
from  the  strain  of  doing  it.  In  treatment  by  modified  toxines, 
an  effort  is  made,  first,  to  partially  destroy  the  toxine  by  oxi- 
dation, thereby  attenuating  its  power  and  so  lessening  its  ex- 
citant action  without  wholly  destroying  said  action.  Sec- 
ondly, to  separate  the  toxic  material  by  chemical  precipitation 
from  a  supposed  curative  ingredient,  retaining  the  latter  for 
therapeutic  use.  In  each  method  the  existence  of  an  antitoxin 
is  inferred.  In  the  last,  this  is  supposed  to  be  developed  in  the 
culture  medium,  together  with  the  toxine,  by  the  action  of  the 
pathogenic  organism,  while  in  the  others  it  is  presumed  to  be 
produced  by  the  organic  cells  of  an  individual  animal  organ- 
ism excited  by  the  toxine  to  such  production. 

As  to  Koch's  tuberculins,  the  original  was  a  purely  toxine 
treatment,  by  which  he  sought  to  produce  an  artificial  immu- 
nity against  the  disease  in  the  patient  by  exciting  the  natural 
reaction  of  his  own  organic  cells  to  produce  a  specific  anti- 
toxin in  his  blood.    This  is  Koch's  tuberculin  A,  and  is  made 

384 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

from  tubercle  bacilli  by  extraction  with  a  one-tenth  normal 
soda  solution.    I  take  this  to  be  Koch's  original  tuberculin. 

Tuberculin  O  he  obtains  by  oxidizing  cultures  of  tubercle 
bacilli  by  drying  them,  pounding  them  in  a  mortar,  anrl  then 
forcing  them  through  hydrogen  moncjxide,  FLO,  in  a  cen- 
trifuge. 

We  have  recently  heard  much  of  tuberculin  R.  This  is 
what  is  left  after  tuberculin  O  has  been  taken  off  as  the  upper 
layer.  In  making  tuberculin  O,  what  is  left  is  treated  again 
with  HoO,  and  thus  again  and  again  subjected  to  the  action 
of  oxygen,  until  no  residue  is  left,  the  conversion  into  oxi- 
dized tuberculin  constantly  going  on.  If  pursued  too  far,  the 
resulting  tuberculin  would  be  inert.  This  oxidation  attenu- 
ates the  tuberculin  as  Pasteur  attenuated  his  hydrophobia 
virus,  by  drying  and  pounding  the  spinal  cords  of  rabbits. 
The  more  the  attenuation,  the  less  the  reaction.  Now,  as  to 
all  tuberculins  and  such  remedies,  the  attenuation  is  produced 
by  oxidation,  either  by  Koch's  and  Pasteur's  plans,  as  given, 
or  by  heat. 

Maragliano's  serum  is  an  antitoxin,  and  is  made  by  sub- 
jecting the  blood-serum  of  another  animal  to  the  action  of 
toxine,  and  thus  forcing  the  animal  to  manufacture  the  anti- 
toxin at  its  own  expense,  and  saving  the  individual  upon  which 
it  is  used  that  strain  upon  his  organization.  The  ass  is  nearer 
immune  to  the  tubercle  bacillus  than  most  animals,  and  I 
think  Mulford's  tubercle  antitoxin  comes  through  the  ass. 
Having  seen  exactly  what  these  toxines  and  antitoxins  are, 
it  is  easier  to  analyze  them  and  see  what  we  might  expect 
of  them  as  to  curing  tuberculosis.  Virchow's  objections  to 
Koch's  tuberculin  A  were  that  the  severe  reaction — that  is, 
the  elevation  of  temperature — attending  its  use  was  often  dan- 
gerous. The  actual  results  of  using  it  were  the  softening  and 
disintegration  of  passive  tuberculous  deposits,  and  thus  from 
these  disseminating  the  bacilli  in  abundance  and  lighting  up 
new  foci  of  infection  wherever  these  lodged.  It  is  easy  to  be 
seen  that,  if  used  at  all,  it  should  be  used  only  in  the  very  first 
stages,  and  if  secondary  infection  had  come,  it  might  be  quite 
25  38s 


FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

dangerous.  Koch  claims  these  dangers  are  eliminated  by  oxi- 
dation of  the  tuberculin,  and  thus  its  attenuation,  and  that 
tuberculin  R  can  be  used  with  impunity. 

Let  us  hope  on  until  hope  has  been  realized.  Neither  Hora- 
tio Wood  nor  Joseph  McFarland  are  hopeful.  Wood  says, 
as  all  can  see,  when  the  tubercle  bacillus  grows  in  the  human 
lung,  the  toxine  which  it  forms  slowly  kills  the  tissues  and 
produces  ulceration.  At  the  same  time  it  finds  its  way  into 
the  blood  and  produces  hectic  fever  and  other  symptoms  we 
so  often  see.  Now,  if  Koch's  tuberculin  (tuberculin  A,  I  sup- 
pose he  refers  to)  is  injected  into  the  individual  in  small  quan- 
tities, no  reaction  is  seen,  but  when  this  is  aided  by  the  toxine 
which  has  been  produced  by  the  system  (remember,  tubercu- 
lin A  is  a  toxine),  and  which  is  already  in  the  blood,  the  two 
toxines  together — the  injected  and  that  already  in  the  blood 
— will  produce  reaction  and  hectic  fever.  At  the  same  time,^ 
the  injected  toxine  will  reinforce  that  in  the  blood,  and  the 
two  will  bring  about  rapid  ulceration  of  the  lung  and  dis- 
charge of  the  tubercle.  Even  if  this  ended  in  the  discharge 
•of  every  tubercle  bacillus,  it  would  not  cure  the  patient.  It 
■does  not  help  the  primary  weakness  of  the  patient,  his  inabil- 
ity to  resist  the  onset  of  the  tubercle  bacilli ;  it  does  not  even 
prevent  the  reinfection  of  the  loosened  tubercle.  Indeed,  the 
very  loosening  of  the  tubercle  bacillus  favors  its  entrance 
into  the  lymphatics  and  the  blood-vessels,  and  its  consequent 
dissemination  throughout  the  body. 

Virchow  soon  found  out  that  a  general  tuberculosis  often 
followed  immediately  upon  the  treatment  of  a  local  tubercu- 
losis by  injection  of  tuberculin  A.  This  is  all  undoubtedly 
true,  as  we  see  it  to-day,  but  let  us  "  hope  on,  hope  ever." 
We  have  made  great  progress :  we  have  the  cause  of  the 
disease;  we  know  it  is  an  infectious  disease;  we  know  the 
natural  history  of  the  cause ;  we  know  that  we  can  in  a  great 
measure  limit  the  production  of  that  cause  by  proper  methods, 
by  proper  laws,  and  by  proper  hygienic  rules.  The  protec- 
tion of  the  individual  will  compel  the  enforcement  of  such 
methods,  of  such  rules,  and  of  such  laws. 

386 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

The  bacillus  itself  is  a  parasite,  and  lives  on  the  animal 
body.  The  problem  before  us  is  to  destroy  it  and  its  toxine 
developed  by  it  in  the  animal  body,  and  yet  not  destroy  that 
animal  body.  Let  us  work  and  hope,  and  hope  and  work.  I 
trust  we  shall  yet  triumph.  When  it  comes,  and  may  God 
hasten  the  day,  the  serum  treatment  will  not  be  a  toxine 
serum,  as  the  tuberculins,  but  an  antitoxin  serum,  like  diph- 
theria antitoxin.  Some  animal  will  be  rendered  immune  to 
the  toxine,  and  its  serum  will  be  the  antitoxin  to  the  tubercle 
bacillus  toxine,  and  if  also  to  the  bacillus  itself,  then  we  will 
have  it.  McFarland,  Maragliano,  and  Panquin  are  working 
on  these  lines,  as  well  as  many  others. 

I  will  merely  mention  here  that  epidemic  influenza,  com- 
monly called  "  grip,"  a  word  which  has  been  engrafted  on 
our  language  from  the  French,  has  its  bacillus,  the  bacillus 
of  PfeifTer.  It  comes  in  the  form  of  rods,  single  or  in  chains, 
and  stains  well  in  methylene-blue. 

As  a  preliminary  to  consumption,  we  spoke  of  the  rise  of 
temperature,  etc.,  in  the  evening  as  one  of  the  first  symptoms. 
When  watching  this  symptom,  always  think  of  the  possibility 
of  syphilitic  fever ;  it  acts  almost  in  the  same  way  and  needs 
far  dififerent  treatment.  In  consumption,  mark  the  dry  hack 
when  the  patient  first  lies  down.  Gravitation  from  the  apex 
of  the  lungs  when  standing,  and  the  return  when  first  lying 
down,  causes  this.  It  is  a  mere  physical  symptom.  Keep  up 
examinations  for  tubercle  bacilli ;  they  are  not  always  found 
at  once.  Watch  the  apices  of  the  lungs,  especially  the  left, 
for  dulness  and  changed  rales;  have  the  patient  frequently 
weighed,  and  watch  for  loss  of  weight.  Always  examine  the 
urine  for  sugar  and  other  irregularities;  your  patient,  if 
under  forty,  may  be  diabetic  and  need  attention  to  diet.  Ex- 
amine the  blood  for  anaemia,  and  remember  there  are  latent 
cases,  and  these  may  have  other  foci  than  the  lungs.  If  pos- 
sible, have  infecting  foci,  as  enlarged  lymphatics,  etc.,  re- 
moved. In  my  experience,  hemorrhagic  cases  of  consumption 
are  more  chronic  than  non-hemorrhagic  cases.  The  local 
depletion  retards  the  toxsemia  and  the  secondary  infection. 

387 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Dyspnoea  is  a  sad  complication,  and  laryngeal  complications 
are  among  the  most  distressing.  Pain  is  chiefly  pleuritic, 
and  can  usually  be  alleviated. 

Acute  miliary  consumption  is  a  sad  complication;  here  we 
have  the  shad-roe  lung,  as  Dr.  William  Pepper,  Sr.,  called  it. 
Look  well  here  for  foci  of  general  infection  in  all  parts  of  the 
body,  and  you  will  probably  find  one  or  more ;  and  watch  for 
bacilli  in  the  supta,  the  blood,  even  in  the  faeces  and  in  the 
eye.  Do  not  mistake  it  for  typhoid  fever,  for  malarial  fever, 
or  for  asthma.  Be  careful  you  do  not  mistake  any  case  of 
tuberculosis  for  malarial  fever.  This  ought  not  to  happen 
now,  with  a  proper  use  of  bacteriology.  Tuberculosis  of  any 
kind  may  follow  typhoid  fever;  here  the  system  is  in  good 
shape  for  the  successful  reception  and  attack  of  the  bacillus. 
Keep  your  wits  about  you;  remember  the  family  history, 
the  environment  of  your  patient;  watch  the  rational  signs 
carefully,  one  and  all,  and  take  in  all  of  the  physical  signs, 
with  the  aid  of  auscultation,  percussion,  and  bacteriology,  not 
forgetting  the  heart  and  large  arteries.  Do  not  let  the  brassy 
cough  of  an  aortic  aneurism  pressing  on  the  recurrent  laryn- 
geal deceive  you  as  to  its  origin,  or  whooping-cough  or  ma- 
lignant troubles  about  the  chest  throw  you  off  the  track ;  and 
remember  that  malignant  and  septic  troubles,  other  than  those 
of  tuberculous  origin,  may  affect  the  organs  of  the  chest,  as 
well  as  of  other  parts  of  the  body.  Senn  says  he  believes 
many  cases  of  supposed  carcinoma  are  nothing  more  than 
cases  of  some  form  of  tuberculosis.  Senn  is  a  great  surgeon, 
and  good  authority.  Do  not  forget  to  hold  this  matter  in 
mind.  If  such  mistakes  have  been  made  in  the  past,  they 
should  not  be  made  in  the  future.  It  is  well  to  remember 
that  the  insane,  the  feeble-minded,  and  weaklings  generally 
are  especially  prone  to  tuberculosis. 

As  to  the  use  of  tuberculin  for  diagnostic  purposes  in  man, 
it  is  scarcely  proper  to  use  tuberculin  A  in  case  the  patient 
has  tuberculosis.  As  to  tuberculin  R,  if  one  wishes,  he  may 
use  it  as  an  additional  help  to  diagnosis.  I  do  not  think  it 
would  do  harm.     Tuberculin  A  is  used  a  very  great  deal 


FORTY    YEARS    IN    THE   MEDICAL   PROFESSION 

among  cattle,  and  the  reaction  here  after  its  introduction 
never  fails  to  take  place  if  the  animal  is  tuberculous. 

In  the  work  done  in  the  matter  of  tuberculosis  among  cattle 
by  Dr.  Neale  and  his  coworkers  of  the  Delaware  Agricultu- 
ral Station,  I  had  an  opportunity  of  investigating  whether 
or  not  there  was  any  antagonism  between  the  bacillus  of  tu- 
bercle and  the  bacillus  of  anthrax.  I  had  hoped  there  might 
be,  and  at  first  there  was  evidence  of  some  antagonism,  but 
it  did  not  bear  closer  investigation,  and  the  results  of  the 
work  were  negative.  To  lessen  tuberculosis  among  human 
beings,  it  is  our  duty,  first,  to  lessen  the  number  of  tubercle 
bacilli  abroad  in  the  world.  To  do  this,  we  must  get  rid  of 
the  great  causes  producing  them.  In  the  second  place,  it  is 
necessary  to  endeavor  to  raise  up  the  human  race  to  a  point 
of  health  where  susceptibility  will  decrease  and  place  them 
under  conditions  where  they  will  not  be  so  prone  to  the  at- 
tacks of  the  bacilli.  I  believe  syphilis  to  be  one  of  the  greatest 
factors  in  rendering  the  human  race  vulnerable  to  the  tubercle 
bacillus,  and  this  factor  reaches  from  generation  to  genera- 
tion, "  the  sins  of  the  fathers"  being  visited  upon  the  chil- 
dren. 

Our  greatest  hope  to-day,  in  dealing  with  human  tubercu- 
losis, is  in  its  prevention.  Personally,  I  believe  the  State 
should  go  to  extremes  in  this  matter,  and  at  the  same  time 
the  unfortunate  owner  of  infected  and  infecting  animals 
should  receive  some  compensation.  There  is  no  manner  of 
doubt  that  the  milk  of  a  tuberculous  cow,  especially  if  she 
have  tuberculosis  of  the  udder,  will  infect  man  with  tuber- 
culosis. I  believe  the  milk  will  infect  if  the  udder  is  sound. 
I  believe  the  meat  of  an  infected  animal,  if  eaten  by  man, 
will  produce  tuberculosis  in  man  unless  it  has  been  sterilized 
by  heat  or  in  some  other  way.  Then  what?  \Miy  should 
man  allow  such  a  menace  to  his  health?  Why  not  eradicate 
it  as  far  as  possible  ?  Why  dilly-dally  ?  We  are  doing  better, 
but  are  not  yet  radical  enough.  Whilst  statesmen  and  poli- 
ticians and  poor,  weak  humanity  falter,  the  brightest  and  best 
among  us  are  the  constant  victims  of  a  cruel  and  cowardly 

3S9 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

hesitancy.  In  France  and  Germany  the  inspection  of  beef 
animals  is  the  most  advanced.  All  animals  are  rigidly  in- 
spected after  they  have  been  killed.  If  tuberculous,  certain 
parts  are  allowed  to  be  sold  and  are  marked  as  tuberculous, 
and  full  directions  are  given  how  to  cook  it  to  make  it  safe 
for  human  food.  Go  to  our  cattle-yards  and  you  can  pick  out 
the  tuberculous  cattle,  and  most  of  them  are  cows.  They  are 
often — not  always — thin  of  flesh,  and  they  cough.  "  Cough- 
ers"  is  the  name  the  dealers  give  them.  Another  name  is 
''  Boulogneys." 

Not  to  take  up  time  and  space,  I  will  give  a  few  statistics 
showing  the  fearful  presence  of  tubercle  among  our  food 
animals.  In  Copenhagen,  out  of  132,294  bullocks  and  cows 
slaughtered  for  food,  23,305  showed  evidence  of  tubercle. 
Out  of  8292  pigs,  1272  were  tuberculous.  Even  369  calves 
out  of  185,765  showed  evidences.  Only  one  sheep  out  of 
337,014  showed  evidence.  Here  is  a  practical  point  and  an 
object-lesson.  In  Berlin,  out  of  142,874  cattle  slaughtered, 
21,603  showed  evidence.  Of  518,073  hogs,  there  were  7055 
showing  evidence  of  the  tubercle.  Of  108,348  calves,  125 
were  tuberculous.  Of  355,949  sheep,  only  15  were  con- 
demned. In  Edinburgh  a  number  of  cows  were  killed  on 
account  of  the  appearance  of  pleuropneumonia  there.  Forty 
per  cent,  of  these  were  tuberculous.  Here  is  an  object-lesson 
in  city-kept  cows  with  generally  bad  environment. 

The  tubercle  bacillus  is  of  general  distribution.  It  is  in  all 
expectorations  of  the  tuberculous ;  it  is  on  their  persons  and 
hands;  it  is  in  the  houses,  in  cars,  in  boats,  in  the  dust  of 
houses,  and  in  the  dust  of  the  streets,  and  the  more  it  is  blown 
about  and  distributed  the  worse  it  is.  They  love  to  be  dried 
and  remoistened;  they  revel  in  such  treatment.  In  our 
houses  brooms  should  be  abolished;  heavy  hangings  and 
heavy  carpets  should  be  much  curtailed;  also  upholstered 
furniture.  Carpet-sweepers  and  moist  cloths  should  take  the 
place  of  brooms  and  dusters.  The  aseptic  house  will  come 
after  a  while,  and  cars  and  all  such  places  of  congregation 
and  resort  will  be,  in  a  measure,  aseptic,     Man  will  be  more 

390 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

careful  in  his  herding.  Individual  bedsteads  will  take  the 
place  of  the  present  abomination, — particularly  of  the  United 
States, — the  double  bedstead.  No  two  persons  should  occupy 
one  bed  as  a  rule  of  domestic  life,  and,  if  possible,  every  indi- 
vidual would  be  the  better  of  a  separate  room  or  apartment. 
All  these  reforms  accomplished,  we  will  then  ai)proach  the 
condition  where  the  aseptic  individual  is  possible. 

In  my  own  State,  Delaware,  from  what  I  can  learn  from 
having  been  active  in  starting  the  work  of  investigation,  and 
from  information  gathered  from  my  friends  and  coworkers, 
I  am  sure  twenty  per  cent,  is  a  small  estimate  of  the  number 
of  our  milch  cows  tuberculous.  In  New  Jersey  there  are 
probably  as  many,  and  in  Pennsylvania,  from  the  investiga- 
tions of  Professor  Leonard  Pearson,  there  are  probably  more; 
but  active  interference  there  has  of  late  reduced  the  percent- 
age. All  herds  should  be  tested  with  tuberculin;  it  is  sure, 
and  Dr.  James  Law,  the  expert  of  Cornell,  says,  from  a  large 
series  of  experiments,  it  does  no  injury  whatever  to  the  sound 
cow.  It  is  the  gilt-edged  herds  that  need  watching  most. 
Choice  breeding  and  selection,  the  environments  of  the  palace 
stables,  and  want  of  out-door  life  are  active  causes  in  breed- 
ing the  bacilli  and  rendering  such  cow^s  fit  subjects  for  their 
attack.  So,  again,  are  the  cows  kept  w^ith  bad  environment 
in  towns  and  cities.  It  is  equally  important  that  no  attendant 
on  dairy  cows  should  be  tuberculous,  and  every  effort  should 
be  made,  by  spraying  water  around  the  stables,  to  keep  down 
all  dust  whilst  men  or  animals  might  be  subject  to  its  influ- 
ences, for  by  dust  the  bacilli  are  most  frequently  spread 
around.  The  natural  life  of  the  cow  is  in  the  free  and  open 
country.  West  of  the  Mississippi  River  horned  and  other 
animals  are  the  most  robust.  They  have  a  more  natural  en- 
vironment, and  the  bacillus  tuberculosis  does  not  thrive  so 
well  in  the  pure  dry  air  of  that  region. 

Again  let  me  say,  I  look  upon  this  question  of  tubercle  ba- 
cilli, in  our  meat  and  milk  supply  particularly,  as  a  burning 
one.  This  source  throttled,  and  the  mortality  of  tuberculous 
diseases  would  diminish  greatly,  and  instead  of  being  our 

391 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

greatest  foe,  would  become  a  minor  evil.  To-day  it  is  through 
milk  that  a  great  many  of  our  so-called  summer  diseases 
among  children  are  tuberculous.  As  it  is,  we  must  sterilize 
or  Pasteurize  these  foods,  watching  that  we  do  not  go  too 
far  in  removing  all  their  freshness  and  causing  scorbutic 
troubles.  Men  who  appreciate  the  horrors  of  the  situation 
must  take  these  matters  up  and  educate  the  people,  who  for 
their  self-preservation  must  act;  surely  they  will  act.  To 
bring  about  proper  legislation  will  take  money,  for  I  do  not 
believe  in  taking  the  private  property  of  the  individual,  even 
for  the  public  good,  without  some  proper  compensation.  Pur- 
suing this  matter,  by  the  light  thrown  out  on  the  way  by 
science  and  scientific  men,  we  will  in  the  end  see  mankind 
immeasurably  benefited,  and  the  human  race  saved  from  the 
horrors  and  sufferings  now  so  relentlessly  imposed  upon  it 
by  many  or  all  of  the  so-called  zymotic  diseases. 

Here  let  me  say.  Lupus  vulgaris  is  a  very  interesting  affec- 
tion, and  its  tuberculous  origin,  owing  to  the  work  of  Henry 
W.  Stelwagon,  Duhring,  and  others,  is  now  well  known.  The 
great  point  is  to  distinguish  it  from  syphilitic  lupus  and  from 
rodent  ulcer,  and  to  cure  it.  It  comes  to  little  children  from 
being  fondled  often  by  tuberculous  parents  or  nurses.  I 
would  not  hesitate  to  use  tuberculin  R  here,  and  study  its 
action,  watching  it  closely.  Everything  should  be  done  to 
prevent  autoinfection  and  the  infection  of  others.  It  is  my 
rule  always  to  impress  this  on  my  tuberculous  patients.  The 
spitting  habit,  always  vulgar  anyhow,  should  especially  be 
avoided.  Persons  are  beginning  to  appreciate  this,  and  the 
authorities  are  becoming  active.  Houses  cannot  be  kept  too 
clean,  and  especially  dishes,  knives  and  forks,  spoons,  and 
such  used  by  the  invalid.  The  temporary  spit-cup  should  be 
used,  or  cloths  or  porous  paper,  and  these  frequently  burned 
up.  All  clothing  or  bedclothing  used  by  the  invalid — better, 
the  clothing  of  all  in  the  house — should  be  frequently  boiled 
one  hour,  or  roasted  at  a  high  heat  in  ovens,  or  disinfected  by 
formaldehyde  fumes,  and  all  apartments  should  be  frequently 
fumigated  with  formaldehyde.    If  there  is  hereditary  tendency 

392 


FORTY    YEARS    IN    THE   MEDICAL   PROFESSION 

in  one  or  more  of  your  families,  watch  them  closely  from 
infancy  to  forty  years  of  age.  Especially  watch  mothers  and 
nursing  babies.  Do  not  allow  a  tuberculous  woman  to  nurse 
a  child,  or  even  care  for  a  child,  nor,  above  all,  to  sleep  in 
the  same  apartment  with  it. 

The  very  serious  question  comes  up,  Shall  we  isolate  con- 
sumptives? "  Blood  is  thicker  than  water."  We  cannot  do 
it  until  by  isolation  we  can  promise  cure  or  hope  of  cure. 
Then  we  can  talk  of  isolation  absolute,  not  before. 

As  to  the  medical  treatment  of  tuberculosis,  find,  first,  the 
focus  or  foci  of  infection.  Call  in  the  surgeon,  if  any  of  these 
can  be  removed.  Pulmonary  tuberculosis  is  the  common  trou- 
ble, of  course.  If  the  digestion  is  good,  use  the  stomach  for 
the  strongest  nourishment  in  every  possible  form,  both  direct 
and  indirect  nourishment,  and  this  is  all  it  is  necessary  to.  say. 
I  differ  from  most  physicians.  If  the  patient  is  a  user  of 
tobacco,  let  him  continue  it  to  the  full  extent  of  his  enjoy- 
ment. It  is  as  good  a  germicide  as  creosote  and  all  such 
stuff  that  is  given,  and  has  just  as  good  a  chance  of  reaching 
the  pathogenic  germ  or  its  toxine,  and  the  smoke  inhaled  is 
worth  all  the  other  inhalations  so  universally  used,  and  gives 
the  otiuiii  cum  dignitate  without  the  accompanying  opium  aim 
digitale.  Of  course,  if  your  patient's  circulation  is  weak- 
ened by  the  tobacco,  curtail  it;  for  we  want  no  points  of 
stasis  as  a  starting-point  for  new  foci  of  infection. 

Through  the  lungs  is  one  of  the  most  available  channels 
to  reach  the  bacilli,  for,  as  external  causes  of  infection  go, 
they  reach  the  general  system  as  frequently  through  the  lungs 
as  they  do  through  the  ingestion  of  tuberculous  substances. 
In  children  I  believe  the  bacilli  enter  with  the  milk  and  en- 
throne themselves  in  the  delicate  intestinal  epithelium  as  the 
most,  to  them,  available  method  of  reaching  the  system.  The 
stronger  intestinal  epithelium  of  the  adult  is  not  so  available 
as  the  resting-place  of  the  pathogenic  germ,  and  here  the  lung 
becomes  the  most  available,  and  thus  we  reach  more  of  them 
through  the  lungs.  Never  give  nauseating  expectorants  to 
your  consumptive  patients,  nor  opium  if  it  upsets  them.    Chlo- 

393 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

ral  and  such  remedies  are  far  better.  Upset  the  digestion, 
and  you  do  great  injury,  irreparable  injury,  indeed.  Give 
cod-Hver  oil,  if  it  can  be  taken  with  advantage,  and  emulsions 
only  if  the  crude  oil  cannot  be  assimilated.  Alcohol  is  a 
sheet-anchor  in  checking  retrograde  tissue  change,  and  has 
doubtless  some  germicidal  action.  Man  is  the  only  fool  who 
takes  alcohol  as  a  beverage.  Counterirritations,  as  a  rule,  I 
have  abandoned,  and  have  relegated  them,  with  the  moxa 
and  the  actual  cautery,  to  the  realm  of  the  barbarous  ages, 
where  they  belong  and  always  did  belong. 

We  have  learned  much  about  tuberculosis  of  the  bones,  and 
these  the  surgeon  deals  with.  There  is  only  one  point  here, 
and  a  very  practical  one,  and  we  should  study  it,  each  from 
his  own  experience.  Does  the  cure  of  a  tuberculous  ailment 
not  of  a  serious  character  change  the  focus  of  distribution  of 
the  pathogenic  germs,  and  thus  more  speedily  infect  vital 
organs  like  the  lungs?  The  same  question  we  may  put  to 
ourselves  in  gynaecological  tuberculosis.  There  is  one  thing 
the  gynaecologists  have  taught  us :  we  can  cure  tuberculous 
peritonitis  by  laparotomy  as  a  preliminary  treatment.  In  the 
treatment  of  pulmonary  hemorrhage  it  is  a  mistake  to  use 
ergot,  a  remedy  so  much  and  so  erroneously  used.  It  only 
increases  the  trouble  by  its  action  on  the  vasomotor  system. 
The  proper  remedies  are  trinitrin  and  such  remedies  as  de- 
crease the  blood-pressure.  The  older  physicians  used  blood- 
letting to  produce  the  same  effect.  It  was  effective,  but  the 
result  was  obtained  by  the  long  way  around.  I  have  had  no 
experience  with  the  method,  but  I  cannot  help  referring  to 
Dr.  Murphy's  proposed  method  of  treating  pulmonary  tuber- 
culosis. 

Murphy  claims  that  nature  cures  consumption  by  a  deposit 
of  connective  tissue  around  the  focus  of  infection.  Anything 
favoring  this  will  cure  the  disease.  He  illustrates  by  a  tuber- 
culous knee-joint.  Set  it  at  rest,  and  new  tissue  forms  and 
the  cure  comes.  Rest  is  necessary.  We  have  ninety  square 
metres  of  respiratory  surface  in  the  lungs ;  we  can  live  with 
half  of  that  surface,  or  much  less  for  mere  existence  without 

394 


FORTY    YEARS   IN   THE   MEDICAL   PROFESSION 

exertion.  The  lung  has  great  capacity  to  repair  itself  should 
there  he  solution  of  its  continuity.  We  coffer-dam  the  dis- 
eased spot,  and  nature  makes  the  cure.  There  are  three  ways 
to  do  this.  First,  remove  a  rih,  or  ribs,  and  allow  the  chest 
to  contract  over  the  diseased  region.  Secondly,  open  the 
chest  and  inject  some  non-poisonous  substance  into  the  pleu- 
ral cavity,  a  substance  that  will  remain  a  long  time  unab- 
sorbed.  This  method  is  similar  to  allowing  the  chest  wall  to 
collapse  by  the  removal  of  the  ribs.  He  recommends  nitrogen 
gas  for  this  purpose.  The  gas  remains  for  months  unab- 
sorbed,  and  the  cure  goes  on.  There  may  be  slight  dyspncea 
after  the  injection,  but  this  soon  passes  off.  The  operation 
is  simple,  with  little  pain  or  discomfort.  Murphy  thinks  the 
dangers  of  compressing  the  lung  too  suddenly  and  of  the 
gas  entering  the  veins  are  possible,  but  not  probable.  I  see 
the  instrument-makers  already  have  out  the  whole  apparatus 
for  the  purpose  as  devised  by  Dr.  Murphy.  Murphy's  third 
method  is  much  like  his  first:  open  the  chest  and  allow  the 
wall  to  sink  over  the  seat  of  the  disease. 

The  philosophy  of  cure  in  consumption  is  to  check  the 
ravages  of  the  cause,  the  tubercle  bacillus.  If  checking  the 
ulceration  caused  by  the  toxine  generated  by  the  pathogenic 
germ  will  cure  consumption,  Dr.  Murphy  is  on  the  right 
track.  If  his  method  leaves  the  author  of  this  ulceration  and 
toxaemia  to  go  free,  and  to  come  time  after  time  and  repeat 
his  work.  Dr.  Murphy's  methods  will  not  cure  consumption. 
The  difficulty  in  consumption  is,  the  disease  is  usually  local, 
and  does  not  produce  immunity  after  infection.  Again,  we 
have  the  secondary  or  mixed  infection  to  contend  with  as  the 
case  advances,  and,  so  far  as  we  know  of  remedies  at  present, 
this  makes  the  case  hopeless.  Murphy  is  right,  the  forma- 
tion of  fibrous  tissue  around  the  foci  of  infection  is  the  only 
cure,  so  far  as  we  know,  but  this  is  the  spontaneous  method, 
nature's  method.  The  logical  plan,  then,  is  to  spur  on  nature 
to  effect  the  cure,  and  to  curtail  the  evolution  of  the  tubercle 
bacilli,  the  great  first  cause.  The  number  of  spontaneous 
cures  of  consumption  is  greater  than  we  dream  of,  and  the 

395 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

number  of  cases  of  surgical  and  other  cases  of  tuberculosis 
recovering  is  very  large.  More  than  half  of  the  human  race 
are  tuberculous,  and  more  than  half  of  these  die  of  tuberculo- 
sis in  one  form  or  another,  and  in  those  vi^ho  do  not  die  of  it 
it  generally  becomes  latent  or  is  cured,  and  they  die  from  some 
other  cause. 

The  question  presenting  itself  to  us  now  is,  What  is  the 
great  factor  in  holding  tuberculosis  latent,  or  in  curing  it? 
So  far  as  we  know,  it  is  climate  and  environment ;  and  could 
all  the  unfortunate  victims  of  tuberculosis  avail  themselves 
of  such  resources  we  would  see  a  great  diminution  in  the 
number  of  victims.  As  we  go  north  and  west,  in  our  own 
country  particularly,  we  find  such  atmospheric  conditions  and 
such  altitudes  as  conduce  to  the  comfort  and  well-being  of 
the  tuberculous,  because,  by  the  altitudes  and  state  of  the 
atmosphere,  the  almost  constant  presence  of  sunlight  in  day- 
time, the  conditions  are  sterilized,  immunized,  and  strength- 
ened. The  almost  entire  absence  of  humidity,  the  low  tem- 
perature, the  altitude,  the  pure  air,  cause  increased  respiration, 
and  hence  the  number  of  red  corpuscles  in  the  blood  is  in- 
creased, and  the  oxygenizing  power  of  the  blood  is  of  course 
enlarged.  In  these  high  altitudes  persons  going  there  at  first 
suffer  from  embarrassed  respiration  to  a  greater  or  less  de- 
gree. This  is  caused  by  the  diminution  of  the  atmospheric 
pressure  causing  increased  action  of  the  heart.  These  symp- 
toms usually  subside  in  a  few  days,  and  a  tolerance  of  the 
environment  is  established.  Epistaxis  may  come  on,  from 
vasomotor  activity.  You  will  say  hemorrhage  from  the  lungs 
will  probably  come  on,  and  may  be  an  element  of  danger.  As 
a  rule,  persons  with  unsound  lungs  will  not  suffer  from  pul- 
monary hemorrhage  in  high  altitudes ;  they  may  suffer  more 
than  those  with  sound  lungs  from  embarrassed  respiration,  on 
account  of  encroachments  of  disease  upon  their  normal  lung 
space,  but  they  will  not  be  apt  to  bleed  from  the  lungs,  for 
the  reason  that  the  excessive  vasomotor  activity  will  drive  the 
blood  out  of  the  deep  viscera,  such  as  the  lungs,  and  thus 
deplete  them  and  render  them  less  liable  to  bleed.    Thus,  then, 

396 


FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

we  have  the  two  explanations :  the  nose  bleeds  because  vaso- 
motor activity  renders  it,  a  superficial  organ,  plethoric,  and 
the  lungs,  the  deeper  organs,  depleted. 

Reasoning  from  what  we  have  said  in  regard  to  the  blood- 
cells,  etc.,  why  would  not  blood  be  a  remedy  to  check  the  on- 
ward course  of  tuberculosis?  I  have  tried  it  faithfully  in  a 
number  of  cases,  the  patients  going  to  the  slaughter-houses 
and  drinking  it  hot  from  the  animals.  I  have  seen  refined, 
delicate  women  drink  it  thus  without  the  least  repugnance. 
I  never  saw  it  do  any  real  good,  after  considerable  observa- 
tion. The  patients  were  always  enthusiastic,  and  expressed 
and  argued  themselves  better,  but  each  went  to  the  common 
melancholy  end  of  the  great  majority  of  consumptives.  I 
have  travelled  extensively  through  our  Western  country,  both 
recently  and  in  the  early  days.  There  is  a  prevailing  impres- 
sion in  all  of  the  high  altitudes  that  the  tubercle  bacillus,  from 
a  lack  of  moisture,  will  not  live,  or  at  least  will  not  thrive,  at 
an  altitude  of  over  five  thousand  feet,  and  some  say  even  four 
thousand  feet.  I  believe  there  is  much  truth  in  this  as  far  as 
the  open  air  is  concerned.  Now,  at  five  thousand  feet  build 
a  town,  or  at  ten  thousand  feet,  the  altitude  of  Leadville, 
Colorado,  erect  your  modern  houses,  furnish  them  with  mod- 
ern furnishings,  and  heat  them  up  to  the  modern  standard 
of  75°  F.  Here  you  have  builded  a  palace  and  an  elysium 
for  the  king  of  pathogenic  germs,  and  from  this  we  can  draw 
our  moral  of  the  treatment  of  consumption :  High  altitude, 
dry  air,  sunlight,  little  or  no  artificial  heat,  and,  whenever 
possible,  in  the  open  air,  and  in  a  tent  rather  than  in  a  house, 
at  any  time. 

The  Indian  is  an  object-lesson.  Turn  him  out  wild,  and 
he  is  vigorous,  hale,  and  hearty,  if  only  he  can  be  held  aloof 
from  the  selfish  designs  of  the  white  man.  Bring  him  into 
civilization,  give  him  houses  and  lands  and  all  modern  com- 
forts, what  is  the  result?  The  deadly  tubercle  bacillus  finds 
in  him  a  victim  after  his  own  heart,  and  the  poor  Indian  soon 
yields  to  his  relentless  charges.  A  few  years  ago  the  United 
States  army  had  recruited  for  it  some  companies  of  Indians. 

397. 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Great  care  was  taken  to  choose  only  the  best  of  a  very  large 
number  offering.  The  result  was  melancholy.  As  soon  as 
they  were  brought  under  army  discipline  in  barracks  they 
began  to  fail,  and  consumption  made  such  inroads  upon  them 
that  the  authorities  were  compelled  to  abandon  the  effort  for 
Indian  soldiers.  I  saw  the  last  company  in  barracks  at  Fort 
Douglass,  Utah,  in  1894.  They  were  a  fine-looking  set  of 
men,  but  nearly  all  of  them  showed  incipient  signs  of  con- 
sumption, and  in  a  few  days  all  were  discharged  and  returned 
to  their  natural  environment.  Fortunate  men,  that  they  could 
so  easily  regain  conditions  where  nature  might  restore  them, 
or  at  least  check  their  rapid  march  to  the  grave. 

Thousands  living  in  the  parts  of  the  world  where  consump- 
tion runs  rife,  unrestrained  by  any  natural  influences,  must 
bear  and  suffer  unless  they  have  pecuniary  means  with  which 
to  seek  more  congenial  climates.  Can  this  large  class  be 
helped  at  home?  Can  we  do  anything  for  them  as  they  pass 
on  through  all  of  the  stages  to  the  last,  the  secondary  infec- 
tions? Can  the  antistreptococci,  the  normal,  immunized,  or 
other  serums  avail  them  here?  Can  pneumotherapy,  can 
pneumatic  differentiation,  help  them  over  the  thorny  path? 
If  people  could  only  be  scattered,  scattered  in  their  residences, 
scattered  in  their  towns;  and  this  can  only  be  done  by  scat- 
tering the  towns.  Have  no  slums.  The  dwellers  of  cities, 
owing  to  the  increased  facilities  for  near-by  travel  offered 
both  by  steam  and  electricity,  are  scattering  more  and  more 
into  suburban  homes,  thus  relieving  the  crowded  centres. 
This  will  surely  have  a  good  effect  on  the  tuberculous  and  on 
those  with  tuberculous  tendencies.  Take  the  world  over,  I 
do  not  care  whether  it  be  in  the  dry  high  altitudes  or  on  the 
moist  and  level  plains  of  the  seaboard,  the  cases  of  tuberculo- 
sis, the  deaths  from  tuberculosis,  vary  as  the  density  of  the 
population  varies, — the  denser  the  population  the  greater  the 
number  of  victims.  In  the  city  of  New  York,  with  81,828 
dwellings,  there  were  during  the  last  five  years  deaths  from 
tuberculosis  in  18,771  houses.  In  the  fourth  ward,  in  248 
houses,  there  were  541  cases  of  tuberculosis  in  three  years. 

398 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

In  many  houses  the  continued  recurrence  of  tuberculosis  is 
reported.  Here  is  a  good  object-lesson  and  its  sad  story, 
from  which  we  may  gather  ins])iration  for  rcff>rm,  which 
leads  us  t(j  infer  that  to  check  tubercuUjsis  entirely  we  must 
discard  towns  except  for  business,  discard  houses  and  their 
surroundings  for  tents,  destroy  all  infected  animals,  give  up 
our  modern  luxuries  in  travel,  and  go  back  to  primitive  times, 
in  order  to  drive  out  the  modern  monster,  the  bane  of  our 
civilization.  Society  will  not  do  this,  but  modern  methods 
and  modern  ideas,  guided  by  the  ever-spreading  and  expand- 
ing light  of  science,  will  take  hold  of  this  scourge  and  will 
in  the  end  conquer  it,  so  far  as  nature  allows  her  methods  to 
be  interfered  with  by  man. 

As  to  climatic  treatment,  we  can  make  the  ideal  climate  at 
or  near  our  homes,  provided  our  homes  are  not  in  favored 
regions;  this  we  can  do  by  placing  our  patients  in  sanitaria 
and  sanatoria  now  rapidly  coming  into  vogue  for  the  pur- 
pose. There  are  many  in  this  country,  and  many  in  Europe. 
Insurance  societies  in  Germany  are  establishing  them  for  the 
treatment  of  their  clients,  and  such  societies,  I  think,  will 
come  sooner  or  later  in  this  country,  and  thus  solve  a  problem 
for  the  man  of  limited  means.  For  the  opulent  we  have  many 
already.  They  are  only  a  make-shift.  When  possible,  the 
patient  should  move,  bag  and  baggage,  to  the  proper  climate, 
and  make  it  his  home.  Years  ago,  consumptives  went  to  mild 
winter  climates  only.  The  only  reason  was  to  avoid  taking 
cold.  This  did  good,  saving  the  onset  of  cold  through  the 
extremities  by  chilling  the  nerve  extremities,  causing  conges- 
tions reaching  to  the  lungs  themselves,  and  establishing  new 
foci  of  infection.  This  was  all,  the  surroundings  were  reek- 
ing with  the  pathogenic  germs,  and  were  in  every  way  unde- 
sirable. 

When  the  great  Northwest  began  to  expand,  forty  years 
or  more  ago,  experience  showed  that  consumptives,  if  in  the 
preliminary  stages,  did  well  there.  St.  Paul.  Minnesota,  be- 
came quite  a  resort.  Experience  was  right,  although  we  then 
knew  nothing  of  the  cause  of  the  disease.    St.  Paul  had  a  dry, 

399 


FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

bright,  sunny  atmosphere  and  many  other  desirable  quaHties 
as  a  residence  for  the  tuberculous.  The  altitude  was  not  suffi- 
cient, and  the  thermometer  went  too  low  at  times,  and  the 
mid-winter  thaw  was  against  it.  For  sanitarium  treatment 
in  place  of  special  climate  and  altitude  treatment,  we  may 
make  the  case  conform  to  the  surroundings,  and  it  need  not 
be  necessary  to  take  into  consideration  the  age,  condition  of 
the  heart,  the  stage  of  the  disease,  etc.,  all  of  which  must  be 
thoroughly  looked  into  before  we  order  our  patients  away  for 
climatic  or  altitude  treatment. 

Now,  as  to  the  sanatorium  treatment  of  tuberculosis.  First, 
as  to  the  two  words  as  they  are  used,  sanatorium  and  sanita- 
rium. The  former  is  really  the  proper  word,  and  both  are 
of  rather  recent  coinage,  rendered  necessary,  like  other  new 
words,  by  the  world's  progress.  They  are  both  derived  from 
the  Latin  verb  sanare,  to  heal,  whence  we  have  sanitas,  health, 
and  sanus,  sound, — sound  health.  Sanatory  is  derived  from 
sanator,  one  who  heals.  Sanitary  is  derived  from  sanitas, 
health.  Sanitary  refers  to  a  condition.  Sanatory  refers  more 
to  action  towards  the  condition.  I  should  incline  to  speak  of 
a  large  resort  for  invalids,  without  special  methods  of  treat- 
ment, or  where  treatment  and  pleasure  were  combined,  as  a 
"  sanitarium,"  A  private  hospital,  or  an  institution  not  ex- 
actly a  hospital,  but  at  the  same  time  devoted  altogether  to 
the  care  and  treatment  of  invalids,  whether  general  or  spe- 
cial, I  would  call  a  "  sanatorium."  The  Century  Dictionary 
gives  sanatorium  as  the  proper  word,  and  the  word  sanitarium 
as  an  improper  use  of  the  word  sanatorium.  I  rather  incline 
to  the  definitions  I  have  given. 

Treated  at  home,  consumptives,  or  patients  having  any 
form  of  tuberculosis,  should,  first  of  all,  live  as  near  as  pos- 
sible out  of  doors,  and  dress  for  the  weather.  They  should 
exercise  absolute  personal  cleanliness,  and  care  for  the  expec- 
torations, etc.,  so  as  to  burn  them  up.  They  should  have  a 
room  to  themselves,  if  in  the  house,  and  exercise  all  means 
to  prevent  infection  of  friends  or  premises.  This  is  the  gist 
of  home  sanatorium  treatment. 

400 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

General  hospital  treatment  is  nf)w  becoming  more  and  more 
an  open-air  treatment,  even  if  the  patients  are  bedridden. 
This  helps  the  patient,  and  lessens  the  liability  of  infection 
to  others  and  to  the  premises. 

The  popular  sanatorium  rest-cure  is  about  the  same  in  all, 
and  is  about  as  follows :  Selecting  the  spot  in  the  proper  loca- 
tion, at  a  proper  elevation,  and  with  the  proper  atmosphere, 
sunlight,  and  surroundings,  the  sanatorium  is  established. 
First,  there  must  be  absolute  cleanliness  of  buildings  and  sur- 
roundings, and  the  patients  must  be  examined  before  admis- 
sion, to  see  that  the  case  is  a  proper  one,  so  far  as  the  heart, 
etc.,  are  concerned,  for  the  environment.  The  altitude  should 
not  be  less  than  four  thousand  five  hundred  feet.  Disinfection 
must  be  thorough  and  continuous,  to  protect  both  the  sick 
and  the  well  who  are  compelled  to  live  in  the  sanatorium  to 
care  for  them.  The  expectoration  of  patients  must  be  burned, 
every  drop  of  it.  Rooms  and  floors  must  be  washed  daily. 
All  dust  must  be  burned,  and  all  utensils  must  be  boiled,  par- 
ticularly napkins  and  towels,  after  each  using.  For  the  "  rest- 
cure,"  a  gallery  is  built  opening  to  the  south.  Here  absolute 
rest  is  taken  all  day  in  chairs  and  beds.  After  three  or  four 
months  of  this  treatment,  short  walks  are  indulged  in  around 
the  grounds,  where  are  arranged  seats  and  sun-boxes.  The 
head  and  eyes  must  be  protected  from  the  sun.  The  surround- 
ing air,  if  the  sanatorium  is  properly  located,  is  perfectly  dry, 
and  on  this  account  the  doors  and  windows  of  the  sleeping- 
rooms  are  always  open,  the  patient  avoiding  drafts  as  much 
as  possible.  If  the  least  chilly,  the  patient  must  always  sum- 
mon an  attendant  with  hot-water  bags  and  wraps.  If  the  tem- 
perature of  the  patient  runs  above  normal,  a  cold-air  bath  in 
the  sun  is  used  to  check  it,  much  as  we  use  cold  water  for 
typhoid  and  other  fevers.  Food,  rest,  open  air,  and  sunlight 
are  the  remedies  used,  without  much  medicine.  This  method, 
closely  followed,  is  affecting  cures  in  from  six  months  to 
three  years,  or  even  longer. 

These  methods  are  particularly  applicable  to  the  weak 
and  delicate  cases  and  those  too  far  advanced  or  too  much 
26  401 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

complicated  with  secondary  infection  for  rough-and-tumble 
life.   , 

There  are  some  favored  spots  in  the  world  where  the  in- 
habitants never  take  cold,  and  instances  are  given  which  show 
that  colds  are  surely  infectious  diseases,  the  infection  being 
carried  by  human  beings ;  that  it  runs  a  definite  course ;  and 
that  one  attack  for  a  certain  length  of  time  confers  immunity, 
thus  showing  a  pathogenic  germ  to  be  the  cause.  In  my  own 
case  I  have  an  object-lesson.  I  have  made  a  number  of  sea- 
voyages  ;  nearly  every  time  I  have  come  ashore  and  mingled 
with  the  busy  world;  in  about  from  forty-eight  to  seventy- 
two  hours  I  have  taken  a  cold,  which  has  run  the  usual  course 
of  colds.  It  is  said  of  Nansen  and  his  men  that  during  their 
three  years'  residence  in  the  Arctic  regions  not  one  of  them 
ever  took  a  cold,  yet  they  were  constantly  exposed  to  cold, 
wet,  and  fatigue.  So,  of  the  members  of  an  expedition  for 
three  years  in  Franz  Josef  Land,  none  ever  took  a  cold.  As 
soon  as  these  people  returned  to  the  civilization  of  the  Tem- 
perate Zone  they  took  colds.  Men  living  in  Spitzbergen,  away 
from  the  centres,  keep  well.  As  soon  as  they  go  to  the  coast 
settlements  they  take  cold.  On  the  island  of  St.  Kilda,  away 
beyond  the  western  Hebrides,  about  one  hundred  people  re- 
side. The  coast  is  inhospitable,  and  only  for  about  four 
months  in  the  year  can  vessels  approach  it.  The  people  are 
always  well,  and  never  have  colds  during  the  eight  months 
of  non-intercourse  with  the  outside  world.  So  soon  as  a 
vessel  arrives,  then,  in  a  few  days,  every  man  woman  and 
child  on  the  island  has  a  cold. 

These  are  wonderful  object-lessons,  and  cause  us  to  think 
deeply.  We  will  probably  utilize  such  places,  but  we  must 
do  it  with  certain  restrictions  as  to  intercourse  with  the 
outer  world,  and  bar  the  luxuries  of  our  advanced  civiliza- 
tion, and  thus  bar  out  the  pathogenic  germs  of  consump- 
tion, pneumonia,  influenza,  and  all  zymotic  diseases.  Thus 
by  prevention,  through  fresh  air  and  sunshine,  we  can 
really  do  much  more  for  our  patients  than  by  saturating 
them  with  creosote,  guaiacol,  and  such  remedies,  which  have 

402 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

a  vaunted  germicidal  power,  yet  a])|)car  to  be  in  little  or  no 
way  specific  remedies. 

The  sanatoria  are  all  very  well,  and  ^ome  of  the  rigid  rules, 
as  to  antisepsis,  of  these  institutif)ns  should  be  carried  to  our 
homes,  our  hotels,  our  steamships,  our  sleeping-cars,  our 
places  of  amusement,  and  particularly  our  churches  and  our 
schools.  Our  boarding-schools  and  colleges  should  come 
imder  rigid  inspection,  and  sanitary  schools  in  aseptic  regions 
will  in  the  future  be  a  proper  safeguard  for  boys  and  girls 
who  may  be  delicate,  with  bad  family  histories. 

As  to  the  general  resorts  for  consumptives,  carried  on  com- 
mercially in  the  western  part  of  our  country,  such  as  large 
hotels  and  the  so-called  sanitaria  and  boarding-houses,  my 
advice  to  invalids  is  to  give  them  a  wide  berth.  I  have  trav- 
elled through  a  great  deal  of  that  country,  and  been  in  a 
number  of  them,  and  among  the  saddest  of  sights  is  to  see  a 
large  roomful  of  consumptives  comparing  notes,  coughing 
and  spitting  during  the  whole  time,  the  atmosphere  and  fur- 
nishings and  the  company  themselves  reeking  with  tubercle 
bacilli,  and  deluded  with  the  idea  that  they  are  doing  what 
is  best  for  them  to  do  to  regain  health,  which  never  under 
such  conditions  can  be  regained,  but  all  going  faster,  under 
the  circumstances,  to  their  sad  and  inevitable  end,  and,  worse 
than  all,  laying  the  foundation  for  just  such  horrors  in  those 
around  them  not  yet  infected.  Those  who  go  away  for  health 
want  to  avoid  the  crowd;  they  need  to  live  as  nearly  alone 
as  possible,  and  they  want  to  be  well  enough  and  strong 
enough  to  take  active  exercise,  to  live  in  the  open  air  almost 
entirely.  Ranch  life  is  the  ideal  life,  and  the  nearer  com- 
panionship is  reduced  to  the  horse  and  the  blanket,  the  better 
chance  will  the  patient  have  of  cure.  The  ''one  Jungers,"  as 
the  natives  call  them,  patients  with  a  cavity,  or  honey-combed 
or  solid  apex,  can  enjoy  this  life  and  improve  greatly  and. 
prolong  life  indefinitely  if  only  secondary  infection  has  not 
set  in.  After  that  has  come,  the  unfortunate  consumptive 
should  not,  as  a  rule,  leave  home,  especially  if  diarrhoea  and 
other  weakening  troubles  accompany  it. 

403 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

As  to  altitude,  it  is  best  to  ascend  gradually.  Do  not  go 
to  ten  thousand  feet  at  once.  Probably  four  thousand  to  six 
thousand  feet  is  best.  Individual  peculiarities  may  assert 
themselves,  and  compel  changes  from  time  to  time.  If  the 
case  is  one  of  fibroid  consumption,  be  very  careful  of  too  high 
elevation,  as  well  as  in  cases  of  laryngeal  tuberculosis.  As 
to  this  last,  the  great  desideratum  is  to  be  within  reach  of  a 
good  physician,  and  to  get  a  place  absolutely  free  from  dust ; 
and  increase  the  altitude  slowly,  at  least.  Always  examine 
the  heart  of  your  consumptive  patients  before  you  send  them 
away,  and  note  any  deviation  from  the  normal.  Do  not  send 
your  cases  with  hypertrophy  of  the  heart  suddenly  to  high 
altitudes,  and  cases  of  weak  dilated  heart,  never.  Diabetics 
do  not  do  well  in  high  altitudes;  the  heart  is  very  irritable, 
and  the  blood-pressure  increases  the  urine  outflow. 

So  far  as  I  can  determine,  the  United  States  and  Mexico 
have  the  best  climates  in  the  world  for  the  tuberculous,  and 
the  best  of  these  are  in  Colorado,  Arizona,  New  Mexico,  and 
old  Mexico.  In  our  Adirondack  region  many  find  a  congenial 
home,  but  I  think  the  good  care  and  treatment  they  receive 
there  has  as  much  or  more  to  do  with  it  than  the  climate.  The 
elevation  is  only  about  two  thousand  feet,  and  there  is,  as  a 
rule,  too  much  moisture.  This  applies  to  all  of  our  country 
in  the  East  of  two  thousand  feet  elevation  or  less.  The  North 
Carolina,  South  Carolina,  and  Georgia  climates  are  fair,  and 
have  some  places  with  good  accommodations  at  about  two 
thousand  feet,  but  there  is  too  much  moisture,  and  too  many 
invalids  are  crowded  together  to  make  such  places  desirable, 
unless  one  can  have  a  cottage  of  his  own.  Florida  is  too 
moist,  and  the  temperature  varies  considerably.  Here  the 
crowds  of  sick  and  delicate  people  are  an  objection,  if  in  hotel 
life.  I  do  not  like  southern  California,  especially  on  the  coast, 
yet  it  is  a  delightful  place  to  spend  a  winter;  but  it  is  too 
hospitable  a  home  for  the  pathogenic  germ.  Minnesota,  Ne- 
braska, and  Dakota  have  an  elevation  of  about  one  thousand 
feet,  and  are  in  places  fairly  dry  and  pleasant.  In  Colorado 
the  climate  is  very  dry,  and  at  times  very  cold,  and  is,  as  a 

404 


FORTY    YEARS    IN    Till-:    MICUICAL    PROFESSION 

rule,  mOvSt  desirable  for  those  aljle  to  take  exercise  anrl  live 
out  of  doors.  Much  the  same  may  be  said  of  parts  of  Wyo- 
ming and  Montana,  and  parts  of  New  Mexico  and  Arizona. 
Here  we  can  get  elevations  of  from  four  thousand  to  as  high 
as  fourteen  thousand  feet,  if  we  choose  to  go  to  the  top  of 
Pike's  Peak  in  Colorado.  The  ideal  climate,  I  think,  is  the 
warm  and  dry  climate  of  southern  New  Mexico  and  southern 
Arizona,  with  an  elevation  anywhere  from  three  thousand  to 
five  thousand  feet.  At  the  Las  Vegas  Hot  Springs,  New 
Mexico,  there  is  a  sanitarium  well  cared  for,  where  both  sick 
and  well  can  spend  a  pleasant  winter  or  make  a  pleasant  home. 
This  is  not  fclr  from  Santa  Fe  and  Albuquerque,  and  in  a 
very  pleasant  part  of  the  country.  Silver  City,  New  Mexico, 
is  in  a  good  location,  one  of  the  best,  indeed,  and  the  sur- 
rounding country  gives  opportunities  for  persons  who  can 
rough  it.  The  town  itself  is  not  overrun  with  invalids.  In 
Arizona,  Phcenix  is  a  desirable  place,  and,  taking  it  as  a 
centre,  one  may  choose  widely  and  establish  a  home  in  some 
available  locality.  Those  who  go  to  such  places  should  go 
with  a  view  of  taking  up  a  permanent  residence  and  estab- 
lishing a  home.  If  they  get  well,  it  will  not  be  safe  to  leave 
for  five  years,  at  least,  and  in  that  time  they  make  new  friends 
and  the  old  homes  change,  often  so  much  as  to  make  the 
return  a  sad  one,  and  the  disease  may  light  up  again  in  the 
moist  climate. 

There  is  one  thing  to  remember  in  choosing  a  climate  for 
the  tuberculous. — the  individual  is  the  important  factor. 
Study  and  observe  well  the  individual.  The  idiosyncrasies 
of  one  person  may  make  a  place  in  every  way  improper, 
which  would  suit  another  exactly.  Remember  what  those 
persons  seek  who  migrate  searching  for  health :  as  far  as  the 
tuberculous  are  concerned,  they  seek  a  place,  first,  where  the 
pathogenic  germ  does  not  thrive;  secondly,  where  they  may 
best  maintain  the  natural  immunity  inherent  in  all ;  and 
thirdly,  where  they  may  best  establish  and  hold  an  artificial 
immunity  to  the  germ.  The  surroundings  are  important,  and 
very  important  matters  are  occupation  and  amusement,  and 

405 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

proper  food  and  clothing.  I  have  advised  many  patients  to 
change  their  residences  on  account  of  tuberculosis,  and  I  have 
watched  many  who  have  changed  who  were  not  under  my 
personal  care.  Those  going  to  Europe  for  travel,  and  then 
locating  on  the  Mediterranean  and  in  other  genial  climates, 
have,  as  a  rule,  not  done  well.  The  life  generally  is  tiresome, 
and  not  suited  to  an  invalid  unless  a  home  is  established. 

There  are  many  sanatoria  (especially  in  Germany),  as  at 
Goibersdorf,  Falkenstein,  Hohenhonnef,  Nordach,  and  Rei- 
boldsgriine.  These  may  suit  the  Germans.  We  have  them 
just  as  good  at  home,  and  in  a  much  better  climate.  Besides, 
I  do  not  believe  in  crowding  the  tuberculous  either  in  houses, 
in  districts,  or  in  communities.  We  want  to  separate  them. 
If  crowded,  asepsis  as  to  the  individual,  his  belongings,  his 
food,  his  surroundings,  in  fact  in  all  conceivable  ways,  must 
be  perfect,  for  both  his  own  protection  and  for  the  protection 
of  others.  Those  persons  I  have  sent  away  who  have  done 
best  are  young  men  and  women  of  moderate  means,  who, 
after  their  location,  were  compelled  to  take  up  some  employ- 
ment for  a  livelihood.  Those  who  went  into  the  country,  or 
roughed  it  on  ranches  and  in  such  employments,  did  best.  A 
number  have  located  in  Denver,  Colorado.  They  generally, 
at  my  advice,  took  employment  where  they  could  get  plenty 
of  outside  air.  They  made  friends,  they  have  done  well  in  a 
business  way,  they  have  established  homes,  some  have  fami- 
lies, and  most  of  them  are  prospering  in  mind,  body,  and  es- 
tate. The  secret  was,  the  necessities  of  existence  drove  them 
to  work,  they  became  interested  and  separated  from  their 
fears  and  evil  forebodings  as  to  their  condition  of  health,  and 
the  result  was  in  every  way  good.  On  the  other  hand,  I  have 
known  a  number  who  had  everything  in  this  world,  in  a 
pecuniary  way,  to  make  them  happy.  They  went  for  long 
visits,  and  generally  in  the  winters;  of  course,  they  put  up 
at  the  best  hotels,  crowded  as  they  were  with  brothers  and 
sisters  in  suffering.  The  result  was  always  bad,  and,  as  a 
rule,  they  would  have  been  better  and  safer,  and  perhaps  lived 
longer,  in  their  own  comfortable  homes  in  the  East. 

406 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

Another  class,  yoimi;-  iiicii  of  means,  in  the  incipient  stajjes 
of  piihnonary  tiiherculosis,  start  to  travel,  and  spcnrl  a  season 
in  the  Riviera.  They  hve  luxuriously  at  the  hotels  and  clubs, 
and  a  society  life  in  general.  Of  course,  they  deteriorate; 
they  come  home  and  go  West  for  a  home ;  they  settle,  per- 
haps in  the  city  or  town,  where  they  meet  the  Ijest  society 
and  have  the  best  time.  They  live  at  the  club  usually,  and 
live  an  idle,  listless  life.  They  suffer  from  ennui,  of  course, 
and  nothing  can  shake  them  up  to  activity  of  any  kind.  The 
result  is  bad,  and  the  remorseless  disease  completes  its  work 
in  about  the  average  time  of  the  average  case.  Had  such 
men  gone  West  and  at  once  started  out  on  the  trails,  away 
from  the  civilization  of  the  towns,  taken  up  ranch  life  of  some 
sort,  and  lived  with  their  horses  and  blankets,  their  chances 
of  recovery,  or  of  lives  greatly  prolonged,  would  have  been 
excellent.  In  such  cases  lies  the  moral  of  the  whole  treatment 
of  tuberculosis  by  climatic  conditions.  It  depends  as  much 
upon  the  individual  and  his  actions  as  it  does  upon  the  climate 
and  the  environment  in  general. 

Before  I  close,  let  me  return  once  more  to  the  captivating 
and  hope-inspiring  subject  of  serotherapy  in  tuberculosis,  and 
give  the  experience  of  Dr.  J.  Edward  Stubbert,  of  the  Loomis 
Sanatorium  for  Consumptives,  at  Liberty,  Sullivan  County, 
New  York.  The  matter  is  from  his  report  for  the  six  months 
ending  May  i,  1898.  The  altitude  at  Liberty  is  tw'o  thousand 
three  hundred  feet.  Patients  do  better  there  in  winter  than 
in  summer,  although  the  year  round  they  do  w^ell.  The  at- 
mosphere is  dry  and  the  sunlight  is  abundant.  The  cold 
northwest  winds  do  the  patients  good  and  not  harm.  They 
walk  through  snow  two  feet  deep,  and  improve  by  such  work. 
He  allows  all  patients  whose  evening  temperature  does  not 
go  above  100°  F,  to  w'alk  moderately,  and  if  the  temperature 
does  not  go  over  99°,  no  restriction  whatever  in  regard  to 
exercise  is  placed  over  them,  even  up  to  or  exceeding  walking 
ten  miles  or  more  a  day.  We  try,  he  says,  to  improve  the 
general  nutrition  of  the  patients,  in  order  to  enable  them  to 

overcome  a  specific  poison.    As  to  medicines,  he  uses  creosote, 

407 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

oil  of  cinnamon,  ichthyol,  and  guaiacol  valerianate.  Ichthyol 
in  keratin-coated  pills  is  best,  especially  if  there  are  intestinal 
complications.  I  suppose  Dr.  Stubbert  looks  upon  it  as  exer- 
cising a  local  germicidal  action  here,  as,  no  doubt,  this  is  the 
great  field  for  creosote  and  all  such  remedies.  Hot  air  inhala- 
tions were  used  in  about  thirty-five  per  cent,  of  the  cases,  with 
encouraging  results. 

Now,  as  to  the  serum.  I  agree  with  Dr.  Stubbert  in  the 
following  statement,  when  he  says,  "  I  am  not  ready  to  pin 
my  faith  to  serotherapy  in  tuberculosis,  but  in  view  of  the 
fact  that,  so  far  as  bad  results  are  concerned,  it  has  proved 
negative,  and  that  a  comparatively  fair  number  of  cases  have 
apparently  improved  under  its  administration,  I  believe  it  to 
be  the  duty  of  the  profession  to  continue  clinical  investigations 
along  this  line."  He  says  the  cases  treated  in  New  York  City 
in  private  practice  by  Dr.  Loomis  and  himself  as  yet  give  rise 
to  no  positive  conclusions.  Loomis's  experience  in  hospital 
patients  in  New  York  City  gave  entirely  negative  results  as 
to  improvement.  Stubbert  says  the  good  effects  appear  to 
be  reduction  of  temperature,  decrease  of  tubercle  bacilli,  and 
probable  immunity  conferred  upon  patients  after  returning 
to  their  homes.  He  says  he  has  discarded  its  use  in  the  sana- 
torium except  in  incipient  cases.  The  serum  he  used  in  his 
cases  reported  was  the  United  States  government  serum  of 
de  Schweinitz.  Now,  I  take  it  this  serum  is  a  tuberculin, 
the  tuberculin  A  of  Koch,  without  attenuation  by  oxidation. 
Therefore  it  is  a  toxine,  and  not  an  antitoxin.  Let  me  give 
here  his  recapitulation  of  the  number  of  cases  treated : 

Whole  number  of  cases  treated 82. 

Expectoration  decreased  in 82  per  cent. 

Appetite  improved  in 81  per  cent; 

Weight  gained  in 78  per  cent. 

Physical  signs  improved  in 82  per  cent. 

Temperature  decreased  in 49  per  cent. 

Bacilli  disappeared  in 13  per  cent. 

Apparent  immunity  established  in 21  per  cent. 

Bacilli  decreased  in 35  per  cent. 

Cough  decreased  in 79  P^i"  cent. 

Generally  improved 85  per  cent. 

r  408 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

This  surely  is  not  a  discouraging  showing,  coming  from  a 
reliable  source.  The  use  of  tuberculin  is  contraindicated  in 
cases  showing"  much  softening  or  cavities,  in  incipient  cases 
with  marked  hereditary  taint,  in  those  in  whom  vital  capacity 
is  much  below  normal,  in  those  showing  rapid  heart  action, 
and  in  most  cases  of  mixed  infection.  In  any  case,  it  is  not 
dangerous  to  inject  the  serum;  occasionally  a  slight  reaction 
occurs  in  the  first  few  treatments.  It  does  not  interfere  with 
digestion ;  where  the  bacilli  have  disappeared  they  have  done 
so  while  the  sputa  were  still  present.  No  report  of  any  relapse 
of  patients  cured  has  been  given,  although  they  may  have 
returned  to  their  former  environment. 

The  most  encouraging  report  from  Dr.  Stubbert  was  in 
regard  to  his  use  of  the  Pasteur  antistreptococcic  serum  in 
six  cases  of  mixed  infection,  showing,  of  course,  the  presence 
of  streptococci  in  the  serum.  The  idea  was  to  neutralize  the 
secondary  infection,  and  give  thus  a  clear  field  for  the  action 
of  the  antitubercle  serum.  The  injection  used  was  about  ten 
cubic  centimetres  each  time.  In  the  first  case  expectoration 
ceased  almost  immediately  for  a  number  of  days  and  then 
returned  in  diminished  quantity.  On  examination,  the  strep- 
tococci were  found  to  be  far  less  numerous  and  smaller  in 
size.  The  next  case  had  had  bronchitis  for  four  years.  Then 
tuberculosis  developed.  This  disappeared  under  antitubercle 
serum,  but  bronchitis  remained.  The  sputa  were  muco-puru- 
lent  and  contained  streptococci.  After  one  injection  of  anti- 
streptococci  serum  cough  and  expectoration  increased  materi- 
ally. After  a  few  wrecks  the  patient  began  to  improve,  and 
the  expectoration  became  very  markedly  less  purulent.  This 
patient  still  lives.  The  next  case  had  a  dry  cavity  at  one 
apex.  The  streptococci  disappeared  after  four  injections  of 
antistreptococci  serum,  and  the  sputa,  after  a  considerable 
time,  still  contained  tubercle  bacilli.  In  the  fifth  case,  the 
antistreptococci  serum  had  no  effect.  The  sixth  case  was  one 
of  tuberculous  meningitis.  Eight  injections  of  antistrepto- 
cocci serum  had  no  effect.  If  the  cause  of  failure  of  anti- 
tubercle serum  is  in  many  cases  mixed  infection,  then  see 

409 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

how  important  the  report  of  the  action  of  antistreptococci 
serum  in  these  cases  becomes,  and  how  encouraging  to  go  on 
with  its  use,  and  how  very  encouraging  to  these  cases  which 
we  have  always  had  to  look  upon  as  so  hopeless  heretofore. 
The  antistreptococci  serum  acts  very  much  more  slowly  in 
these  cases  of  chronic  infection  than  it  does  in  cases  of  acute 
infection. 

It  will  be  remembered  by  the  reader,  that  when,  a  few  pages 
back,  I  spoke  of  the  work  done  in  order  to  test  the  relation- 
ship of  the  bacillus  of  tuberculosis  and  the  bacillus  of  anthrax 
by  Dr.  Neale  and  his  assistants  at  the  Delaware  College  Agri- 
cultural Experiment  Station  at  Newark,  I  was  compelled  to 
record  my  great  disappointment  at  the  negative  character  of 
the  results  of  the  experiments.  I  have  now  by  me  the  Quar- 
terly Bulletin  of  the  Pasteur  Institute  of  New  York  City  for 
December,  1897.  In  it  I  find  an  article  by  its  Director,  Dr. 
Paul  Gibier,  "  Do  Laboratory  Researches  allow  us  to  hope  for 
the  Early  Discovery  of  a  Specific  Remedy  for  Tuberculosis  ?" 
Gibier  was  working-  on  microbic  symbiosis  in  general,  with 
the  object  of  investigating  whether,  by  some  kind  of  vital 
competition  between  the  bacillus  tuberculosis  and  the  various 
other  bacteria,  it  would  be  possible  to  cause  the  latter  to  de- 
velop a  soluble  ferment  giving  the  cells  of  the  animal  organ- 
ism the  power  of  digesting  the  bacillus.  He  inoculated  suc- 
cessfully a  number  of  guinea-pigs  with  the  tubercle  bacilli. 
He  kept  four  animals  as  tests ;  that  is  to  say,  he  allowed  them 
to  go  without  any  treatment  after  they  had  developed  tuber- 
culosis. The  others  he  inoculated  with  a  liquid  obtained  by 
filtering  through  clay  the  cultures  of  a  number  of  bacteria 
which  had  thrived  in  company — symbiositic  bacteria  they 
might  be  called — with  the  tubercle  bacillus.  Injections  were 
made  every  other  day,  the  quantity  of  fluid  being  gradually 
increased  to  two  cubic  centimetres.  The  test  pigs  died  in  two 
and  one-half  months,  three  months,  and  three  and  one-half 
months.  Those  treated  with  the  filtered  liquids  of  the  cul- 
tures of  tubercle  bacilli  and  streptococci,  tubercle  bacilli  and 
staphylococci,  tubercle  bacilli  and  subtiles  and  others,  were 

410 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

not  helped  as  to  tlicir  tiil)crcnlosi.s,  and  died  before  the  test 
])ijn"s.  He  took  twf)  of  the  tuberculous  pigs  and  treated  them 
with  a  li(|uid  of  a  culture  of  tubercle  bacilli  and  anthrax. 
After  receiving  five  or  six  injections,  the  ulcerations  at  the 
points  of  their  tubercle  injections  began  to  heal,  and  their 
inguinal  glands,  before  enlarged,  began  to  decrease  in  size. 
One  of  the  two  tubercle  and  anthrax  pigs  died  accidentally. 
The  other  continued  to  receive  the  combined  tubercle  anrl  an- 
thrax injections,  at  first  every  two  or  three  days,  then  twice 
a  week,  and  then  once  a  week,  for  two  months.  At  the  end 
of  the  two  months,  the  ulcers  had  healed  and  the  glands  had 
gone  down  to  natural  size.  It  was  well,  and  at  the  end  of 
two  years,  when  it  was  killed  accidentally,  it  had  thrived  and 
doubled  its  size.  Other  experiments  in  the  same  line  by  Gibier 
did  not  turn  out  so  encouragingly,  but  he  rightly  argues, 
"  Experiment  in  this  line  is  worth  while,  and  in  the  end  we 
will  by  some  such  means  be  able  to  arrest  the  development  of 
the  tubercle  bacillus,"  and  thus  cure  tuberculosis  in  man  and 
the  lower  animals.    God  speed  the  day. 

Another  method  of  attacking  the  pathogenic  germ  is  by  in- 
halation, and  an  account  of  some  experiments  given  by  Mur- 
rell  in  the  Philadelphia  Medical  Journal  for  February  i8, 
1899,  shows  how  men  are  working  on  all  sides  to  overcome 
this  arch  enemy  of  animal  existences.  He  took  twenty  pa- 
tients suffering  from  pulmonary  tuberculosis  in  various  stages, 
none  of  whom  were  confined  to  bed.  He  arranged  for  them 
to  inhale  once  or  twice  a  day,  and  some  of  them  continuously 
night  and  day,  air  impregnated  with  either  oil  of  cinnamon 
or  oil  of  peppermint.  The  details  were  well  carried  out,  and 
the  results  were  uniformly  ^unfavorable.  In  the  bacteriologi- 
cal examinations  neither  of  the  oils  showed  any  deleterious 
influence  on  the  growth  of  the  tubercle  bacillus.  Experi- 
ments were  made  with  formaldeh3^de  in  forty  per  cent, 
aqueous  solutions,  the  patients  inhaling  a  spray  containing 
one  part  of  this  solution  in  sixteen  of  water ;  at  the  same  time, 
bacteriologic  examinations  were  undertaken  with  a  six  per 
cent,  solution  of  formaldehyde,  and  the  results  proved  most 

411 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

satisfactory  as  regards  its  action  on  the  bacillus  tuberculosis. 
No  contaminations  occurred  in  any  of  the  tubes.  All  the 
controls  grew  "well  except  in  one  agar-agar  tube  sealed  with 
paraffin  in  a  jar,  which  failed  by  an  accident.  No  tube  kept 
under  the  influence  of  formaldehyde  vapor  for  forty  hours, 
ninety-six  hours,  or  ten  days  showed  any  growth  whatever. 
Subcultures  were  made  from  several  tubes  of  the  solid  media, 
and  from  all  the  tubes  of  the  fluid  media.  All  of  these  failed 
except  one  of  glycerin  and  beef-broth  exposed  for  forty-eight 
hours,  which,  reinoculated  on  blood-serum,  began  to  grow 
feebly  after  three  weeks.  A  repetition  of  these  experiments 
gave  the  same  result. 

All  this  shows  that  even  a  weak  solution  of  formaldehyde 
shows  a  marked  inhibitory  influence  on  the  growth  of  the 
tubercle  bacillus,  and  prolonged  for  forty-eight  hours  en- 
tirely prevents  their  growth  and  future  development.  The 
clinical  results  are  quite  up  to  the  bacteriologic  experience. 
The  six  per  cent,  solution  was  usually  employed,  increased  or 
diminished  according  to  the  idiosyncrasy  of  the  patient.  The 
drug  was  inhaled  once  or  twice  a  day,  compressed  air  by  a 
simple  mechanical  arrangement  being  made  to  bubble  through 
the  solution.  Coughing  in  some  cases  was  annoying  during 
the  inhalation.  Out  of  twenty  cases  treated,  six  were  incon- 
clusive, because  not  persisted  in,  or  other  treatment  was  used 
with  the  inhalation.  The  other  fourteen  cases  did  well,  only 
the  inhalation  treatment  being  used.  Twelve  were  decidedly 
benefited,  and  two  were  slightly  improved.  These  cases  were 
in  all  stages  of  the  disease. 

Murrell  recommends,  as  the  best  method  of  treating  pul- 
monary tuberculosis,  to  obtain  bacilli  from  the  expectoration, 
cultivate  them,  pass  over  them  various  volatile  substances 
until  one  is  found  which  will  arrest  their  growth,  and  then 
administer  it  by  inhalation. 

I  have  not  said  much  of  drugs  in  connection  with  tubercu- 
losis, but  the  new  South  American  remedy,  kalagua,  must  not 
be  passed  over,  for  it  really,  on  so  good  an  authority  as  the 

Loomis  Sanatorium  physicians,  shows  great  antiseptic  prop- 

412 


FORTY    YEARS   IN    THE   MEDICAL   PROFESSION 

erties,  in  closes  of  three  grains  three  times  a  clay.  Attention 
was  first  attracted  to  it  in  South  America  by  the  effect  the 
eating  of  the  leaves  had  on  tuberculous  cattle.  It  apparently 
cured  them.  The  remedy  produces  no  ill  effects.  The  analy- 
sis is  given  as  follows:  Water,  8.51 ;  extract  of  ether,  3.01 ; 
albuminoids,  22.19;  ashes,  16.79;  cellular  and  extract  mat- 
ter not  ozote,  49.43.  The  Loom  is  report  gave  five  per  cent, 
apparently  cured,  sixty-two  per  cent,  improved,  fourteen  per 
cent,  stationary,  nineteen  per  cent,  worse.  In  septic  cases 
ichthyol  is  highly  recommended  from  the  same  source,  and 
good  authority  it  is,  too.  It  is  almost  a  specific  in  changing 
purulent  sputum  in  doses  of  from  twenty  to  thirty  grains  a 
day.  The  Sanatorium  also,  in  its  last  report,  gives  more  hope 
from  antitubercle  serum  than  do  most  other  clinicians  at  the 
present  time. 

One  word  more.  We  have  considered  tuberculosis  of  the 
lungs,  bones,  joints,  glands,  and  other  parts,  but  have  not 
spoken  of  the  circulatory  system.  Tuberculosis  is  a  protean 
disease,  the  more  we  study  it.  In  cases  of  heart  disease,  espe- 
cially in  the  young  and  delicate,  whether  of  the  myocardium, 
the  pericardium,  or  the  endocardium,  before  you  relegate  the 
case  to  the  domain  of  rheumatism  or  to  the  class  of  cases  re- 
garded as  idiopathic  from  cold  or  wet,  consider  them  well. 
Cardio-vascular  disease  surely  predisposes  to  tuberculosis  of 
some  form.  Either  the  tuberculous  trouble  or  the  cardiac 
trouble  may  be  primary.  The  tubercle  bacilli  and  its  toxines 
and  other  pathogenic  germs  may  produce  the  heart  trouble. 
The  toxines  are  active  in  producing  the  sclerotic  forms.  The 
bacilli  produce  nutritive  changes  in  the  tissues.  Tuberculous 
lesions  of  the  valves  of  the  heart  are  often  found ;  so  it  is  well 
to  remember  the  possibility  of  this  in  all  cases.  Tuberculous 
pericarditis  is  probably  far  more  common  than  is  usually  sup- 
posed, and  doubtless  the  cause  of  the  condition  is  far  more 
commonly  overlooked  than  diagnosed.  There  is  another  trou- 
ble which  is  very  frequently  of  tuberculous  origin, — acute 
pleurisy.  Remember  this  in  diagnosis,  in  treatment,  and, 
above  all,  in  prognosis. 

413 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Before  I  close  this  chapter  let  me  add  a  note  on  a  practical 
point  in  hay-fever.  Having  been  a  lifelong  sufferer  myself 
from  a  form  of  hay-fever, — the  June  cold,  commonly  called 
the  rose  cold, — I  naturally  take  interest  in  any  matter  per- 
taining thereto.  We  know  it  comes  in  other  forms  besides 
the  June  cold,  the  chief  other  forms  being  the  autumnal  ca- 
tarrh, coming  on  about  August  20,  or  when  the  rag-weed  or 
bitter  weed  (Ambrosia  artemisicEfolia)  blooms,  and  the  peren- 
nial form  which  pesters  its  victims  during  the  whole  part  of 
the  year  when  all  vegetation  is  not  dormant.  I  believe  all 
of  these  forms  have  a  common  cause,  and  that  cause  is  bac- 
terial. Plant  pollen  is  given  as  a  cause.  Vibrios  in  the  nasal 
chambers  have  been  given  as  a  cause,  and  vibrios  are  bacteria. 
Some  claim  it  is  a  neurosis  pure  and  simple.  I  know  all  suf- 
ferers from  hay-fever  are  neurotic  at  the  time  they  are  under 
the  morbific  influences,  and  during  this  time  there  is  occlu- 
sion of  the  nostrils  and  tender  spots  on  the  nasal  mucous 
membrane ;  but  there  is  really  no  essential  diseased  condition 
of  the  nasal  mucous  membrane  as  a  cause,  and  the  neurotic 
condition  is  an  effect  rather  than  a  cause.  As  I  said  before, 
I  believe  the  cause  is  from  pathogenic  germs,  and  these  enter 
with  the  dust  of  the  air  and  cause  the  trouble.  There  is  an 
individual  sensitiveness  to  their  action,  just  as  some  indi- 
viduals are  sensitive  at  times  or  always  to  other  pathogenic 
germs.  I  believe  the  pollen  of  plants  do  their  part,  but  more 
as  a  host  for  the  pathogenic  germs,  and  by  their  natural  irri- 
tating qualities,  than  in  any  other  way. 

Now,  as  to  the  practical  point.  In  investigating  some  mat- 
ters in  connection  with  electric  lighting,  I  met  a  young  man 
who  had  been  a  sorry  sufferer  from  hay-fever  since  he  was 
four  years  of  age.  His  residence  is  Wilmington,  Delaware. 
From  August  20  to  the  first  heavy  frosts  of  each  year  he  has 
been  unfit  for  any  work,  from  asthma  and  other  troubles. 
Three  years  ago  he  went  to  Oakland,  Maryland,  high  up  in 
the  Allegheny  Mountains,  and  worked  in  an  electric-light 
plant,  which  merely  generated  the  current,  but  had  no  storage- 
battery  plant.     He  received  no  benefit  there,  either  from  ex- 

414 


FORTY    YEARS    IN    THE   MEDICAL   PROFESSION 

postire  ill  tlic  works  or  from  tlic  climatic  conditions.  Since 
•last  spring  he  has  worked  in  llic  plant  at  Wilmington,  Dela- 
ware, much  of  the  time  in  the  storage-battery  room.  This 
year  he  has  been  absolutely  well  in  every  way  throughout  the 
hay-fever  season,  and  he  attributes  his  freedom  from  trouble 
to  something  he  breathes  when  in  tlie  storage-battery  room. 

I  examined  this  young  man  during  the  time  he  should  have 
been  suffering.  I  found  him  well  and  strong,  twenty-three 
years  of  age,  weight  one  hundred  and  thirty-five  pounds,  five 
feet  six  inches  high,  with  a  good  family  history,  and  not  a 
hay- fever  subject  by  inheritance.  There  were  a  few  dry  and 
moist  rales  over  the  chest,  such  as  we  might  find  in  any  one 
who  might  have  been  at  times  more  or  less  asthmatic.  He 
told  me  he  was  cured.  I  asked  him  by  what  means?  He 
said  by  inhaling  the  fumes  in  the  storage-battery  room.  "  I 
am  especially  benefited,"  he  said.  "  when  we  are  over- 
charging to  bring  up  low  cells  and  when  the  booster  is  on." 
The  question  now  was  to  find  what  these  fumes  were.  I 
found  upon  questioning  the  very  intelligent  gentlemen  con- 
nected with  the  plant  that  their  idea  was  that  the  fumes  were 
hydrogen  peroxide,  hydrogen  dioxide.  Here  was  an  expla- 
nation consistent  with  my  belief  of  the  cause  of  the  disease, 
the  cause  being  bacterial  and  hydrogen  dioxide  a  destroyer 
of  bacteria;  and  probably  this  patient  was  benefited  in  the 
storage-battery  room  just  as  whooping-cough  patients  are  ben- 
efited in  the  gas-houses  where  illuminating  gas,  carburetted 
hydrogen,  is  made,  the  carbolic  acid  fumes  here  acting  as  a 
germicide  to  the  now  pretty  well  established  cause  of  per- 
tussis. 

In  order  to  more  fully  investigate  what  these  fumes  of  the 
storage-battery  room  might  be.  I  consulted  my  friend.  Pro- 
fessor C.  L.  Penny,  Professor  of  Chemistry  in  the  Delaware 
College  Agricultural  Experiment  Station.  Newark,  Delaware. 
In  giving  me  notes  of  his  examination.  Professor  Penny 
alludes  to  the  young  gentleman,  the  victim  of  the  hay-fever, 
as  saying  that  the  curative  agent  in  his  case  was  hydrogen 
dioxide,  and  that  it  had  to  him  an  unpleasant  odor,  yet  hydro- 

415 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSIO^r 

gen  dioxide  has  no  odor.  "If  the  hydrogen  dioxide  is  the 
curative  agent,  it  must  be  largely  as  carried  into  the  air  by 
the  spray  from  the  bubbling  of  the  battery,  and  in  that  case 
with  some  of  the  dilute  sulphuric  acid.  Whether  it  would  be 
abundant  enough  and  far-reaching  enough,  carried  in  that 
way,  to  do  any  good,  I  do  not  know.  In  view  of  everything, 
it  would  seem  to  me  that  ozone  is  the  one  probable  explana- 
tion of  the  case.  Ozone  has  long  been  known  to  be  evolved 
from  electrolytic  action,  such  as  that  of  battery-charging. 
Where  such  enormous  electrolysis  is  going  on  as  in  the  Wil- 
mington power-house,  and  in  so  small  a  confined  space  as  the 
battery-room,  the  air  must  be  very  highly  charged  with  ozone. 
The  electrolysis  of  less  than  an  ounce  of  acidulated  water, 
with  a  weak  battery  current,  will  emit  an  odor  very  percep- 
tible in  a  room  for  some  feet  around.  Now,  the  amotmt  of 
action  must  be  multiplied  by  many  thousands  to  make  it  com- 
parable with  that  in  the  power-house  at  Wilmington.  Then  I 
do  not  see  anything  improbable  in  supposing  that  there  is,  at 
certain  hours,  enough  of  ozone  in  the  air  of  the  battery-room 
to  have  an  unquestionable  effect  on  floating  organic  matter, 
or  miasms,  and  prove  disastrous  to  them.  We  do  not  know 
certainly  of  any  other  volatile  emanation  from  electrolysis 
than  ozone,  common  oxygen,  and  hydrogen.  So  far  as  I 
know,  no  one  suspects  any  other  such  emanation;  hence  I 
would  say,  with  the  information  available,  that  if  a  curative 
effect  in  the  battery-room,  peculiar  to  that  place  and  not  no- 
ticed elsewhere,  is  unquestionable,  and  if,  as  I  understand  to 
be  the  case,  the  curative  effect  is  noticed  only  or  chiefly  when 
the  liquid  in  the  batteries  is  boiling,  with  evolution  of  gas, 
then  I  would  not  hesitate  to  attribute  the  curative  effect  to 
ozone  as  the  only  body  certainly  known  to  be  present  and 
capable  of  such  effect." 

I  know  one  case  is  little  upon  which  to  base  inference  in 
clinical  medicine,  but  this  case  opens  up  an  interesting  subject, 
and  may  point  the  means  to  relief  and  cure  in  many  cases  now 
only  relieved  by  changes  in  climate  and  residence,  so  incon- 
venient to  all  and  so  impossible  to  the  many. 

416 


FORTY   YEARS    IN    THE   MEDICAL   PROFESSION 

Dr.  Douglass,  of  New  York,  recommends  for  all  forms  of 
hay-fever  the  dried  suprarenal  glands.  I  have  no  doubt  he 
argues  for  this  remedy  on  account  of  its  well-known  property 
of  depleting  the  nasal  mucous  membrane.  It  thus  restores 
the  over-distended  condition  of  the  nasal  erectile  tissue.  He 
uses  it  both  locally  and  as  a  spray,  and  by  tablets  internally 
every  two  hours  until  until  some  prostration  is  manifest. 


27  417 


CHAPTER    XII. 

Rheumatism  an  Infectious  Disease — The  Bacillus  of  Rheumatism — 
Thyroid  Extract  in  Rheumatism — Uric  Acid  in  Rheumatism — Nuclein 
— The  White  Blood-Corpuscles  —  Diagnosis  —  Treatment  —  Rheumatic 
Gout — Multiple  Arthritis  Deformans — Gout — Arteriosclerosis — Meta- 
bolism— Anabolism — Katabolism — Theories  of  Gout — Origin  of  Uric 
Acid — Causes  of  Gout — Gout  of  the  Intestines — Treatment  of  Gout — 
Water — Lithia — Diet  in  Gout — Intermitting  Heart — Alcohol  in  Gout — 
Cider  Cure  for  Gout — Vegetables  in  Gout — Contracted  Kidney — Medi- 
cines in  Gout — Piperazine  and  Pichi  in  Gout — Thyroid  Extract  causing 
Gout — Menstrual  Gout — Carlsbad — An  American  Carlsbad — Diabetes 
Mellitus — Glucose — Starches — Dextrose — Glycogenic  Matter — Tubercu- 
losis and  Diabetes — Pancreatic  Lesions — Carl  von  Noorden — The  Liver 
and  Glycogen — Fat — Hyperglycemia — Causes  of  Diabetes  Mellitus — 
Mayer's  Theory — McCaskay's  Suggestions — Relationship  between  Dia- 
betes and  Obesity  and  Gout  and  Diabetes — Gluten — Diagnosis — Tests 
for  Sugar — Pregnancy  and  Diabetes  Mellitus — Alcohol — Recoveries — ■ 
Diabetes  and  Gouty  Kidney — How  to  watch  a  Diabetic — Diabetic 
Coma — Diabetics  Vulnerable — Diabetics  and  Tuberculosis — Thyroid 
Treatment — Prognosis — Diet  and  Treatment — Jambul  and  Piperazine 
— Substitutes  for  Cane-Sugar — Wines  and  Spirits — Waters — Fruits — 
Nuts — Allowable  Articles  of  Diet — Terrapin — Rest  Treatment — Gluten 
Flours  and  other  Diabetic  Flours  and  Foods — Analysis  of  Macaroni, 
Flours,  etc. — The  Soja  Bean — Aleuronat  Flour — Adulterations. 

Forty  years  ago  Dr.  George  B.  Wood  defined  rheumatism, 
meaning  rheumatic  fever,  to  be  a  constitutional  affection,  at- 
tended with  a  pecuHar  irritation  or  inflammation,  to  which  all 
parts  of  the  system  are  liable.  The  general  definition  to-day 
is,  an  infectious  disease,  with  fever  and  arthritis,  more  or  less 
general.  Some  yet  believe  it  to  be  due  to  a  disturbed  metabo- 
lism, the  nitrogenous  products  being  converted  into  lactic  and 
uric  acids  and  alloxuric  products,  instead  of  being  carried  off 
as  urea.  Hence  we  get  the  highly  acid  perspiration  and  high 
fever.  Probably  a  few  yet  class  it  among  the  neuroses,  like 
the  neuralgias.  Every  day  the  number  grows  who  class  it 
with  the  specific  infections,  as  they  do  typhoid  fever,  dysen- 

418 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

tery,  erysipelas,  and  pneumonia.  Personally,  I  believe  here 
is  where  it  belongs. 

A  French  bacteriologist  claims  to  have  isolated  the  patho- 
genic germ,  an  anaerobic  bacillus  resembling  the  bacillus  of 
anthrax.  It  is  said  to  elaborate  negative  chemotaxic  sub- 
stances, and  also  products  which  produce  necrosis  in  animal 
tissues,  thus  accounting  for  the  heart  lesions  so  often  seen 
in  rheumatic  fever.  Salicylic  acid  is  said  to  affect  adversely 
this  bacillus,  and  the  germ  is  not  usually  found  in  the  blood. 
This  might  explain  why  the  giving  of  thyroid  extract  pro- 
duces rheumatism,  as  has  been  the  experience  with  some,  be- 
cause it  acts  not  specifically  as  thyroid  extract,  but  only  by  the 
pathogenic  germs  it  introduces  into  the  system. 

Whatever  may  be  the  cause,  it  looks  at  present  very  plau- 
sible to  me  that  it  is  caused  by  a  specific  pathogenic  germ 
which  is  destroyed  by  the  exhibition  of  salicylic  acid,  acting 
as  a  germicide.  How  germs  may  act  in  producing  the  disease 
is  for  the  future  to  determine.  They  may  check  the  breaking 
up  of  the  many  compound  waste  substances  in  the  system, 
which  when  broken  up  pass  off  harmlessly  through  the  kid- 
neys and  other  organs.  These  tissue  wastes  may  be  in  the 
form  of  uric  acid  and  allied  substances.  Again,  as  claimed 
by  Bouchard,  rheumatism  may  be  a  toxaemia  resulting  from 
the  decomposition  of  food-stuffs  in  the  stomach  endowed  with 
conditions  favoring  such  decomposition,  such  decomposition 
favoring  the  generation  of  the  peculiar  germs;  not  only  in 
the  stomach,  but  throughout  the  whole  intestinal  tract  may 
these  conditions  be  present. 

What  part  uric  acid  may  play  in  causing  rheumatism  is  an 
interesting  question.  If  rheumatism  is  an  infectious  disease 
of  bacterial  origin,  uric  acid  can  only  play  a  secondary  part 
in  the  causation.  It  is  either  produced  by  or  increased  by 
this  bacterial  action,  or  its  elimination  from  the  system  is 
checked  by  it.  The  same  may  be  true  of  lactic  acid.  As  to 
the  source  of  uric  acid,  Vaughan  says  nuclein  is  broken  up, 
alloxuric  bodies  are  formed,  and  uric  acid,  the  most  highly 
oxidized  of  these  substances,  is  the  chief  representative  in  the 

419 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

urine  of  the  nuclear  metabolism  resulting,  as  here  indicated, 
in  the  body.  Here  we  come  back  to  the  cell,  "  omnis  cellula 
e  cellula,"  and  in  their  life  and  death  we  look  for  the  origin 
not  only  of  life,  but  of  death.  Every  cell  at  some  period  of 
its  life  has  a  nucleus.  The  nucleus  of  a  cell  is  the  part  con- 
cerned in  the  transmission  of  its  life  to  another  cell.  Nuclein 
is  the  material  of  which  the  nuclei  are  composed.  In  health, 
the  nucleus  of  the  red  blood-corpuscle  perfects  it  to  carry  the 
oxygen  and  disappears.  From  Kossel's  experiments  we  know 
that  nucleated  cells  contain,  in  addition  to  nucleinic  acid,  ger- 
micidal basic  substances,  protecting  them  against  bacterial 
invasion.  Here  we  approach  the  claims  of  those  who  insist 
that  we  have  in  nuclein  a  germicide.  Inject  it  into  the  sys- 
tem, and  we  increase  the  number  of  white  blood-corpuscles, 
these  being  the  natural  scavengers  of  the  body,  which  check 
or  prevent  entirely  the  multiplication  of  the  pathogenic  germs 
in  the  body.  These  polynuclear  white  blood-corpuscles  do 
not  eat  up,  as  it  were,  the  germs,  but  destroy  them  by  some 
chemical  action  peculiar  to  themselves.  What  germicidal 
properties  blood-serum  may  have,  inherent  or  acquired,  come 
through  the  polynuclear  white  blood-corpuscles.  Increase 
these  and  you  fortify  the  body  against  the  attacks  of  all  path- 
ogenic germs. 

I  mention  these  somewhat  intricate  facts  and  suppositions 
to  show  that  in  some  part  of  it  we  may  sooner  or  later  locate 
such  diseases,  not  only  as  rheumatism,  but  gout  too,  and  all 
may  arise  from  a  vicious  metabolism  in  all  the  name  implies, 
and  the  cause  of  this  vicious  metabolism  may  be  a  bacterio- 
logical one  and  a  controllable  one.  This  theory  is  more  plau- 
sible because  of  Vaughan's  adherence  to  the  theory  of  Hor- 
baczewski  as  to  the  formation  of  uric  acid  in  the  economy. 
We  have  long  been  taught  that  uric  acid  is  the  result  of  the 
imperfect  oxidation  of  urea,  or  rather  uric  acid  should  have 
gone  to  urea  had  its  completed  oxidation  gone  on.  Horbac- 
zewski  showed  that  the  amount  of  uric  acid  and  other  xanthin 
substances  formed  in  the  body  is  a  measure  of  nuclein  meta- 
"bolism,  the  more  there  is  in  the  body,  the  more  nucleated  cells 

420 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

we  know  are  undergoing  disintegration.  In  such  a  disease 
as  rheumatic  fever  there  must  be  enormous  disintegration  of 
nucleated  cells,  and  here  the  excess  of  uric  acid  may  be  a  result 
and  not  a  cause  of  the  disease.  Compare  rheumatism  with 
the  so-called  gonorrhoeal  rheumatism,  and  we  can  reconcile 
ourselves  more  and  more  to  ordinary  rheumatism  being  a 
germ  disease.  Gonorrhoeal  rheumatism  is  undoubtedly  caused 
by  the  gonococcus,  this  protean  germ  even  attacking  the  heart, 
as  in  mycotic  endocarditis,  and  thus  showing  its  similarity  to 
rheumatic  fever. 

So  far  as  my  experience  goes,  rheumatic  fever  is  a  much 
more  rare  disease  than  it  was  formerly,  say  forty  years  ago. 
Like  all  zymotic  diseases, — if  it  is  a  zymotic  disease, — it  is 
becoming,  indeed,  quite  a  rare  disease.  The  reason  for  this 
undoubtedly  is  the  great  improvement  in  drainage  and  the 
general  improved  environment  of  homes,  whether  in  town  or 
country.  People  are  much  better  clothed  and  much  better 
shod  than  they  were  some  years  ago,  and  the  means  of  travel 
are  so  much  more  comfortable  and  expeditious,  and  hence  less 
conducive  to  colds  and  illness  coming  from  them.  When  the 
germ  theory  as  to  rheumatism  is  settled,  and  afifirmatively, 
there  will  be  little  trouble  in  the  diagnosis.  To-day  our  meth- 
ods of  distinguishing  the  disease  are  about  as  they  were  years 
ago.  It  is  a  disease  rather  of  the  poor  than  of  the  rich,  al- 
though this  applies  rather  more  to  the  chronic  forms  than  to 
the  acute.  The  prognosis  is  much  improved,  on  account  of 
the  improved  and  more  successful  methods  of  treatment,  and 
heart,  brain,  and  spinal  complications  are  more  rare.  Keep 
your  wits  about  you,  and  you  will  rarely  mistake  it  for  an- 
other disease  in  its  ordinary  forms,  but  be  very  careful  when 
you  come  to  its  concealed  forms. 

Years  ago  the  cure  for  rheumatic  fever  was  given  as  six 
weeks  in  bed.  To-day  most  of  the  cases  we  can  control  by 
salicylic  acid  and  its  salts  within  seventy-two  hours.  We 
may  use  them  in  any  form,  by  the  mouth,  by  the  skin  as  in 
ointments,  and  by  the  rectum.  Healthy  surroundings  should 
by  all  means  be  given  the  patient;    indeed,  surroundings  as 

421 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

near  aseptic  as  possible,  and  he  should  never  be  allowed  to 
have  cotton  or  linen  come  next  his  skin.  There  is  nothine 
new  in  diet,  except  it  is  more  liberal  than  that  of  our  fathers. 
I  oppose  all  animal  broths,  such  as  beef-tea  and  the  like,  in 
most  of  the  zymotic  diseases,  because  they  make  good  culture 
media  and  model  hosts  for  pathogenic  germs,  and  for  this 
reason  I  oppose  them  in  rheumatism  in  any  form,  for,  if  it  is 
a  germ  disease,  the  digestive  tract  is  a  place  to  grow  them  par 
excellence.  Should  the  treatment  by  salicylates  not  be  toler- 
ated, we  have  salol  and  such  drugs,  really  much  the  same,  as 
salol  breaks  up  into  salicylic  acid  and  carbolic  acid  in  the  in- 
testines. These  not  agreeing,  or  failing,  use  intestinal  anti- 
sepsis of  different  kinds,  both  direct  and  indirect,  using 
freely  of  alkalies,  with  opiates  to  subdue  the  pain.  Make  all 
affected  joints  as  nearly  immovable  as  possible.  This  method 
gives  great  comfort.  Subacute  and  chronic  forms  now  and 
again  will  yield  to  salicylates  and  germicides  generally.  It 
is  most  important  in  these  cases  to  make  their  surroundings 
comfortable  and  give  them  wool  next  to  the  skin  and  plenty 
of  it.  Intestinal  lavage  does  good  here,  keeping  in  mind 
the  greatly  increased  possibilities  of  auto-intoxication. 

These  rules  apply  to  cases  of  muscular  rheumatism  also, 
particularly  the  intercostal  and  lumbar  types.  See  that  your 
cases  of  chronic  rheumatism  are  well  fed  with  proper  food, 
especially  of  milk  and  bread  and  fish  and  eggs,  and  do  not 
forget  massage  and  electricity;  they  increase  oxidation,  and 
thus  carry  off  the  waste  products.  Cod-liver  oil  is  good  food. 
These  are  generally  alkaline  foods,  and,  reasoning  from  the 
general  acid  condition  of  the  blood  in  all  rheumatic  cases, 
should  be  proper  food.  If  such  patients  waste  away  and  lose 
flesh,  give  them,  freely  even,  of  starchy  food.  Starches  are 
really  diluted  fats,  and  fat  in  diet  checks  the  waste  of  albumin 
in  the  tissues  and  subserves  the  strength. 

Arthritis  Deformans,  Rheumatoid  Arthritis,  or  Rheumatic 
Gout. — I  have  seen  this  much  more  frequently  in  women  than 
in  men,  and  most  of  the  women  have  borne  children.  This 
makes  me  think  there  may  be  something  in  the  neurotrophic 

422 


FORTY   YEARS    IN    THE   MEDICAL    PROFESSION 

theory  of  the  disease  first  put  fortli  Ijy  I  Jr.  Jolin  K.  Mitchell, 
the  elder.  Behind  all  this  there  may  he  a  pathogenic  germ 
working  in  some  mysterious  way,  a  veritahle  polyp.  Cod- 
liver  oil  and  strychnine  are  the  hest  remedies  I  know  of,  with 
wool  clothing,  good  food,  and  an  environment  as  nearly  asep- 
tic as  possible. 

Multiple  Arthritis  Deformans. — I  see  these  much  more  fre- 
quently in  women.  They  are  supposed  not  to  be  true  gout. 
I  am  sure  most  women  who  have  them,  under  favorable  con- 
ditions of  life,  live  to  be  old.  I  am  sure  heredity  plays  a  great 
part  in  their  production,  and  they  appear  to  me  to  nearly  ap- 
proach some  forms  of  gout  or  rheumatic  gout.  If  they  ulcer- 
ate, suppurative  arthritis  is  apt  to  follow.  The  chronic  pro- 
gressive form  may  affect  nearly  every  joint  of  the  body,  and 
the  patient  be  helpless  and  in  a  condition  not  differing  much 
from  ultra  cases  of  rheumatic  gout.  Whether  or  not  uric 
acid  is  present  in  the  blood  in  these  diseases,  as  it  is  in  gout, 
or  absent,  as  it  is  in  rheumatism,  I  do  not  know.  In  the  treat- 
ment of  acute  articular  rheumatism,  and  in  all  forms  where 
pain  is  the  prominent  symptom.  I  believe  the  hot-air  treatment 
will  prove  to  be  of  great  value. 

GOUT. 

It  has  been  truly  said,  "  A  man  is  as  old  as  his  arteries," 
and  the  great  factor  of  all  in  causing  their  loss  of  elasticity 
and  the  lessening  of  their  caliber,  thus  producing  a  true  arte- 
riosclerosis, is  undoubtedly  syphilis ;  the  next  factor  is  the 
abuse  of  alcohol,  and  the  next  is  gout,  followed  by  other  less 
important  causes,  such  as  luxurious  living,  with  a  want  of 
exercise,  the  play  of  the  emotions,  and  the  zymotic  diseases. 
Coming  on  after  this  hardening  of  the  arteries,  we  have  en- 
largement of  the  left  ventricle  of  the  heart,  a  compensatory 
enlargement,  for  the  arteries  are  really  peripheral  assistants 
to  the  heart,  and  when  they  lose  their  elasticity  the  central 
heart  must  beat  more  lustily  to  drive  the  column  of  blood 
through  the  system,  and  hence  we  get  increase  of  blood- 
pressure,  followed,  if  not  by  renal  changes,  which  really  often 

4-23 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

coexist  with  these  troubles  in  the  form  of  contracted  kidney, 
then  by  ohguresia,  the  condition  of  the  heart  and  arteries 
rendering  them  incompetent  to  pump  the  full  blood-stream 
through  the  kidneys,  and  hence,  even  with  sound  kidneys,  we 
have  albuminuria.  Given  renal  casts,  we  may  know  the  kid- 
neys are  yielding.  Such  as  these  are  the  exaggerated  cases 
of  arteriosclerosis,  and  with  them  a  man  has  reached  old  age, 
whether  he  be  forty  years  old  or  ninety.  If  forty  or  under, 
to  bring  on  the  condition  he  has  violated  some  one  or  more  of 
nature's  inexorable  laws.  If  he  has  reached  old  age,  his  con- 
dition is  a  normal  one,  his  sands  of  life  have  about  run 
out,  and  the  rupturing  of  his  hardened  arteries  brings  him  a 
timely  and  natural  passing  to  the  regions  of  the  silent  ma- 
jority. Such  a  case  is  apparent  to  the  trained  diagnostician, 
but  arteriosclerosis  reaches  to  much  more  refined  and  to  finer 
lesions  of  the  economy  than  these.  So  much  so,  indeed,  that 
it  has  been  said  more  than  once  that  a  majority  of  mankind 
really  die  of  arteriosclerosis,  either  of  the  grosser  or  finer 
kinds.  Such  being  the  case,  and  gout  being  one  of  its  great 
factors,  we  should  study  and  investigate  most  thoroughly 
such  an  arbiter  of  human  happiness  and  human  existence. 

Before  taking  up  the  study  of  the  causation  of  gout,  it  will 
be  well  to  pass  in  review  some  matters  pertaining  to  food  and 
its  action  on  the  economy,  including  such  processes  as  meta- 
bolism and  its  congeners,  katabolism  and  anabolism.  I  think 
I  have  before  given  the  definitions  of  metabolism,  katabolism, 
and  anabolism,  but  it  will  do  no  harm  to  repeat  them,  for,  if 
we  do  not  know  them,  we  surely  cannot  appreciate  or  under- 
stand the  supposed  causes  of  gout.  Metabolism  signifies 
change  as  applied  to  tissues,  tissue  change  in  nutrition  and 
secretion.  Katabolism  is  the  process  of  forming  products  of 
secretion — which,  according  to  Virchow,  are  metabolic  prod- 
ucts— by  protoplasm.  This  is  retrograde  metamorphosis. 
Anabolism  is  a  building-up  process,  forming  living  proto- 
plasm from  dead  nutrient  material.    This  is  assimilation. 

Professor  W.  O.  Atwater  has  given  us,  in  speaking  of  the 
uses  of  food  in  the  body,  a  very  good  idea  of  metabolism,  and 

424 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

I  will  make  use  of  it  in  speaking  of  these  matters.  He  thinks 
Liebig's  assertion,  that  chemical  changes  in  the  vegetable  world 
are  synthetic  and  in  the  animal  analytic,  is  true;  but  there 
are  many  exceptions  in  both.  Atwater  thinks  the  physical 
processes  in  the  plant  are  chiefly  the  transformation  of  kinetic 
or  motor  energy  into  potential  energy.  Those  in  the  animal 
are  just  the  opposite, — the  transformation  of  potential  into 
kinetic  or  motor.  Now,  this  is  normal  metabolism.  Normal 
metabolism  is  of  two  kinds,  the  metabolism  of  matter  and  the 
metabolism  of  energy.  These  two  processes  conform,  the  for- 
mer to  the  conservation  of  matter,  and  the  latter  to  the  conser- 
vation of  energy.  This  brings  these  complex  processes  into 
line  with  the  two  fundamental  laws  of  the  conservation  of 
matter  and  the  conservation  of  energy,  and  thus  the  doctrine 
of  nutrition  is  set  on  a  firm  basis.  Atwater  says  the  terms 
"  flesh  formers"  and  "  fuel  values"  are  plainer  terms  than 
protein,  fats,  and  carbohydrates. 

Food  has  two  chief  uses, — to  form  the  tissues  and  to  act 
as  fuel.  In  tissue-building  we  have  the  metabolism  of  matter. 
In  fuel  we  get  the  heat  and  muscular  power,  and  thus  deal 
with  the  metabolism  of  energy.  The  proteins,  as  we  have 
before  stated  when  considering  diet,  are  the  tissue-builders 
chiefly,  but  also  serve  in  a  measure  as  fuel,  the  fats  and  the 
carbohydrates  being  the  chief  fuel  factors.  As  fuel,  the  nu- 
trients replace  each  other  as  to  their  potential  energy.  In  food 
we  must  have  sufficient  of  protein  to  form  tissue  and  sufficient 
energy  from  the  fuel  foods  to  give  heat  and  strength.  In  the 
body  fat  we  have  stored  fuel.  The  fuel  value  of  fat  is  double 
that  of  protein  and  carbohydrates.  Fat  in  the  food  is  stored 
in  the  body  as  fat.  This  is  important.  The  fuel  part  of  the 
proteins  and  the  carbohydrates  must  be  transformed  into  the 
body  fat.  The  fuel  value  of  food  is  its  fat-forming  value. 
To  get  at  the  amount  of  matter  metabolized  we  take  into  ac- 
count the  food  and  the  drink  taken  and  the  oxygen  inhaled 
by  the  lungs.  Much  of  this  goes  to  form  blood,  muscle,  body 
fat,  bone,  etc.  What  is  left  is  outgo,  and  consists  of  the  resi- 
due after  having  made  the  blood,  the  bone,  the  muscle,  the 

425 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

fat,  etc.,  the  worn-out  materials  of  the  body  which  undergo 
chemical  changes  and  go  off  as  gases  through  the  lungs  and 
skin,  the  excreted  urine,  being  composed  of  both  liquid  and 
solids,  the  fecal  matters,  and  the  other  excretions  from  the 
digestive  tract.  All  these  processes  going  on  normally  in  the 
healthy  individual  constitute  normal  or  healthy  metabolism, 
and  such  an  individual  will  not  suffer  from  gout.  So  far  as 
we  know,  the  gouty  individual  is  gouty  because  the  different 
metabolic  processes  going  on  in  his  system  are  abnormal,  and 
the  victim  of  gout  is  the  victim  of  abnormal  metabolism. 

What  causes  this  abnormal  metabolism  is  the  problem  to 
solve.  Does  it  come  through  the  food  primarily,  owing  to 
its  unbalanced  condition  as  a  ration  for  the  individual, — that 
is  to  say,  owing,  for  instance,  to  an  excess  of  nitrogen,  now 
so  generally  claimed, — or  could  it  possibly  be  an  infection,  a 
zymotic  infection,  the  food  eaten  making  the  digestive  tract 
an  acceptable  host  to  the  pathogenic  germ,  this  germ  being 
the  author  of  the  abnormal  metabolism  in  devious  and  remote 
ways,  and  hence  in  the  end  causing  the  excessive  formation 
of  uric  acid  or  its  defective  elimination,  acknowledging  for 
the  time  that  the  pathological  factor  in  gout  is  uric  acid?  I 
am  not  inclined  to  acknowledge  anything  as  proven  irrevoca- 
bly as  the  pathological  factor  in  gout,  and,  such  being  the 
case,  I  see  no  objection  to  theorizing,  or  guessing,  if  you 
prefer  to  call  it  so.  To-day,  I  think  the  chances  of  gout  being 
an  infectious  disease  caused  by  a  pathogenic  germ  or  germs 
are  just  as  great  as  that  uric  acid  in  the  blood  or  system  causes 
it,  or  if  uric  acid  in  the  blood  or  system  does  cause  it,  there  is 
good  reason  to  believe  that  a  pathogenic  germ  or  germs  may 
be  a  direct  or  indirect  cause  of  the  excess  of  uric  acid.  It 
may  be  asked  here  what  part  do  intestinal  microbes  play  in 
digestion?  Their  ferments  may  be  factors  in  digestion,  as 
are  the  enzymes  and  unorganized  ferments.  Bacteria  may 
be  necessary  to  the  physiological  decomposition  of  albumi- 
noids in  the  digestive  process,  and  hence  by  their  absence  or 
greater  or  less  number  may  influence  their  digestion  and  the 

formation  of  uric  acid. 

426 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Again,  taking  this  infectious  view  of  the  origin  of  gout,  we 
know  bile  is  the  great  intestinal  antiseptic  and  the  natural  peri- 
staltic persuader.  Practically,  we  find  in  gouty  attacks  and  in 
lithremic  conditions  a  more  or  less  deficiency  of  bile,  and  hence 
a  clear  intestinal  field  for  the  workings  of  intestinal  microbes, 
as  we  might  suppose  them  to  work,  if  a  pathological  factor  in 
gout.  In  gouty  persons  there  is  this  condition,  it  appears  to 
me  from  clinical  experience  only,  generally  existing,  accom- 
panied by  constipation  and  all  the  conditions  going  to  make 
up  what  we  might  call  an  hepatic  insufficiency,  which  insuffi- 
ciency might  rest  on  the  liver  anatomically  or  upon  some 
defect  inherent  in  it  as  a  producer  of  bile  up  to  the  proper 
standard  for  its  work  in  the  animal  economy. 

Haig  claims  that  calomel  drives  the  uric  acid  out  of  the 
blood  and  into  the  tissues,  and  that  this  causes  an  attack  of 
gout,  for  he  looks  to  uric  acid  as  the  one  cause  of  gout.  On 
the  other  hand,  the  calomel  should  stimulate  the  liver  to  send 
out  an  excess  of  bile  and  render  the  surroundings  antimicro- 
bic  and  check  the  gouty  attack  sooner  or  later.  The  two  sup- 
positions are  not  so  opposite  to  each  other  as  one  might  think 
on  first  examination,  and  may  be  easily  reconciled.  Haig  be- 
lieves all  colds  to  be  caused  by  an  excess  of  uric  acid  in  the 
blood,  uricacidsemia  plus  a  microbe.  I  trust  that  some  day 
he  may  find  out  all  gout  to  be  uric  acid  plus  a  microbe,  or  a 
microbe  plus  uric  acid. 

Haig  writes  entertainingly  and  delightfully,  his  style  is 
charming,  resembling  that  of  Sir  Thomas  Watson  more  than 
any  writer  I  know  of.  His  work  on  uric  acid  in  the  causation 
of  disease  reads  like  a  romance.  Sometimes  I  think  his  en- 
thusiasm runs  away  with  his  judgment;  again  he  resembles 
a  book-keeper  who  forces  his  balances  to  meet  the  conditions 
present.  I  say  this  without  any  feeling  of  disrespect.  I  ad- 
mire his  enthusiasm  and  his  perseverance,  and  only  good  can 
in  the  end  come  from  his  honest  intentions  and  zealous  indus- 
try. Haig  believes  gout  to  be  rheumatism,  and  rheumatism 
to  be  gout,  age  only  varying  the  clinical  aspect,  and  the  cause 
of  all  to  be  uric  acid.    Indeed,  the  presence  of  uric  acid  in  man 

4^7 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

is  a  protean  factor  in  disease,  and  the  cause  not  only  of  rheu- 
matism and  gout,  but  of  many  and  various  ailments  and  con- 
ditions harassing  mankind,  the  latter  diseases  being  caused  by 
the  effect  of  the  uric  acid  on  arterial  tension.  Haig  appears 
to  have  absolute  faith  in  his  ability  to  handle  uric  acid  as  a 
pathological  factor  in  man.  He  claims  to  be  able  to  produce 
artificially  an  arthritis  in  man.  Salicylates,  he  says,  clear  the 
blood  of  uric  acid  by  removing  it  from  the  body,  whilst  acids, 
sulphates,  opium,  mercury,  the  iodides,  iron,  lead,  and  lithia 
remove  it  by  holding  it  in  the  joints,  liver,  spleen,  and  other 
tissues.  By  giving  an  alkali,  he  claims  he  will  produce  head- 
ache, mental  depression,  slow  pulse,  etc.,  by  increasing  the 
excretion  of  uric  acid.  By  giving  an  acid  he  claims  to  cure 
the  headache  by  decreasing  the  excretion  of  uric  acid,  and,  as 
it  is  not  excreted,  it  must  go  somewhere,  and  it  goes  into  the 
tissues  and  joints  and  causes  gout.  This,  I  believe,  is  Haig's 
theory  of  the  action  of  uric  acid  as  a  pathological  factor  in 
gout. 

As  far  as  our  present  knowledge  extends,  we  are,  I  think, 
compelled  to  admit  that  uric  acid  is  a  pathological  factor  in 
gout,  possibly  the  great  pathological  factor,  for  Garrod  has 
shown  us  that  in  an  acute  attack  the  blood  is  loaded  with  it. 
Why  these  metabolic  changes?  Why  these  secretory  prod- 
ucts? Can  there  be  an  infection?  If  an  infection,  is  it  di- 
rectly from  the  living  parasite  or  from  its  poisonous  secretion, 
for  in  diseases  either  the  one  or  the  other  may  be  a  cause  ? 

Metabolism  begins  with  assimilation  and  ends  with  excre- 
tion, and  between  these  boundaries  any  of  these  troubles  may 
arise.  Then,  again,  what  influences  may  be  at  work  here  for 
good  or  for  evil?  What  are  the  functions  of  the  ductless 
glands,  now  being  so  faithfully  studied?  What  effect  has 
.normal  cell  action,  and  what  may  be  the  effect  of  abnormal  cell 
action,  are  questions  constantly  presenting  themselves  when 
we  come  to  study  disease  with  the  ever-increasing  light  of 
the  present  day.  Accepting  uric  acid  as  the  prime  factor  in 
the  causation  of  gout,  what  theory  of  its  formation  shall  we 
accept  ?    Shall  we  take  Garrod's  theory,  that  it  is  the  result  of 

42S 


FORTY    YFiARS    IN    THIi    MEDICAL    PROFESSION 

nitrogenous  waste,  that  it  represents  a  lower  degree  of  oxida- 
tion than  urea,  and  thus,  being  more  or  less  insoluble,  it  is 
not  carried  off  but  accumulates  in  the  system  and  produces 
Haig's  uricacidoimia?  This  accumulation  in  the  system  is 
an  incomplete  waste  product,  and  it  is  here  because  it  is  not 
urea  as  it  sliould  be ;  and  it  is  so  because  of  some  defect  in  the 
liver  interfering  with  its  urea-making  powers.  The  fault  in 
the  liver  is  probably  its  faulty  action  on  the  peptones  in  diges- 
tion. Its  action  on  the  peptones,  if  normal,  causes  the  proper 
formation  of  urea;  if  abnormal,  it  is  only  uric  acid,  much 
lower  in  oxidation  than  urea,  that  is  formed.  In  order  to 
check  this  formation  of  uric  acid  we  withhold  the  nitrogenous 
foods  and  thus  reduce  the  amount  of  peptones  for  this  unfa- 
vorable action  of  the  liver. 

This  is  a  beautiful  theory,  and  really  the  theory  to-day 
upon  which  most  of  our  ablest  clinicians  base  their  theory  of 
the  treatment  of  gout.  I  believe  it  is  about  to  be  pulled  down, 
yet  practically  the  dietetic  part  of  the  treatment  may  not  be 
greatly  changed.  The  prudent  gouty  man  must  semi-starve 
himself  still.  After  all,  this  is  not  unnatural,  for  a  life  of' 
luxury  will  always  have  its  penalties,  for,  as  far  as  man's  ani- 
mal existence  is  concerned,  it  is  an  unnatural  life. 

Now,  as  to  the  other  origin  of  uric  acid,  brought  out  by 
the  work  of  Vaughan  and  others,  which  we  spoke  of  at  length 
when  treating  of  rheumatism.  Here  its  origin  is  given  as  the 
result  of  the  oxidation  of  the  nuclein  of  the  blood-corpuscles. 
In  addition  to  uric  acid,  we  must  also  look  to  the  uric  acid 
group  of  leukomaines  as  a  factor  in  the  causation  of  gout. 
Here  is  a  more  complex  cause,  and  a  better  opening  still  for 
the  workings  of  pathogenic  germs  as  a  near  or  remote  cause 
too.  Here  comes  in  the  nervous  factor.  We  must  look  on 
tliis  uric  acid  and  these  leukomaines,  if  not  normally  formed, 
as  victims  of  a  faulty  metabolism,  or  of  some  faulty  secretory 
functions,  or  may  be  of  germ  origin  so  far  as  the  leukomaines 
are  concerned,  and  these  faults  lie  in  the  nervous  system,  and 
here  we  have  gout  among  the  neuroses.  What  becomes  of 
the  methods  of  treatment  of  our  best  clinicians  of  to-day 

429 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

under  these  circumstances?  They  must  change  their  rigid 
and  fixed  rules  as  to  diet,  especially  as  to  the  absolute  elimi- 
nation of  the  nitrogenous  foods.  Now,  if  gout  may  come 
under  any  suspicion  of  the  infections,  there  may  still  be  a 
good  reason  for  withholding  the  proteids  to  a  greater  or  a 
less  degree. 

I  spoke  in  the  treatment  of  typhoid  fever  of  the  advisability 
of  withholding  animal  broths  in  that  disease,  as  they  were 
available  culture  media  for  the  pathogenic  germ.  The  same 
advice  may  in  a  measure  hold  good  in  gout  and  many  other 
diseases,  and  thus  w^e  may  with  propriety  withhold  in  a  great 
degree  all  foods  serving  to  produce  or  increase  an  auto-intoxi- 
cation, rendered  more  possible  from  the  presence  of  such  foods 
in  the  digestive  tract. 

In  the  treatment  of  gout  my  experience  leads  me  more 
than  in  any  other  disease,  excepting  diabetes  mellitus,  to  study 
well  the  individual,  and  to  become  familiar  with  his  idiosyn- 
crasies, both  mental  and  physical,  and  this,  whether  the  case 
be  chronic  or  acute.  Above  all  things,  study  your  patient  as 
to  his  tolerance  of  nitrogenous  food, — carbohydrates  and  fats. 
All  persons  differ  as  to  their  tolerance  of  these  substances, 
and  particularly  the  gouty  so  differ.  One  gouty  person  may 
eat  roast  beef  and  get  a  colic,  and  another  may  get  a  colic 
from  starchy  food,  or  from  sugar,  or  from  fats.  These  are 
most  important  points  to  remember  in  practice,  and  to  disre- 
gard them  is  empiricism.  The  great  factors  in  treatment  are, 
first,  water  and  plenty  of  it;  second,  semi-starvation, — not 
really  semi-starvation,  but  semi-starvation  only  as  compared 
with  the  inordinate  eating  and  drinking  habits  of  the  average 
man;  third,  salicylic  acid  and  its  salts,  colchicum  and  aperi- 
ents; fourth,  exercise  and  dress,  and  proper  environment, 
with  a  life  regulated  to  bring  about  and  keep  up  the  alkalinity 
of  the  blood,  for  we  know  by  experience  that  our  gouty  pa- 
tients only  do  well  under  this  condition,  be  the  causes  what 
they  may. 

Now,  as  to  the  acute  attack.  If  local,  heat  applied,  even  the 
hot  air,  is  most  grateful.     Local  applications  are  not  usually 

430 


FORTY    YEARS   IN    THE   MEDICAL    PROFESSION 

in  favor,  Init  logically,  I  think  oil  of  gaultheria  might  be 
painted  upon  the  affected  joint.  If  the  disease  is  general, 
push  the  salicylates  and  colchicuni  and  ojjium  if  necessary  to 
stop  the  suffering  as  soon  as  possible.  I  say  opium,  although 
Haig  says  it  increases  the  arthritis  by  driving  the  uric  acid 
from  the  blood  into  the  joints.  The  patient  should  drink 
water  to  his  utmost  capacity,  to  get  rid  of  the  nitrogenous 
waste  through  the  kidneys;  and  after  the  pain  subsides,  so  as 
to  let  up  on  the  salicylates  and  colchicum,  salol  may  be  sub- 
stituted as  more  of  a  germicide  to  the  digestive  tract,  where 
it  breaks  up  into  salicylic  acid  and  carbolic  acid. 

Whilst  it  is  necessary  to  watch  the  patient  closely,  espe- 
cially if  at  all  inclined  to  be  feeble,  rigid  low  diet  is  the  rule, 
and  milk  is  best,  and  not  too  rich  at  that.  Watch  for  retro- 
cessions, for  they  may  come  suddenly  and  bring  disaster. 
The  gouty  patient  is  a  vulnerable  patient,  whether  his  case 
be  acute  or  chronic.  The  disease  is  a  protean  disease,  and  I 
know  of  no  organ  of  the  body,  of  no  function  of  the  body,  of 
no  sense  of  the  body,  whether  special  or  general,  it  may  not 
involve. 

Allow  me  to  speak  of  a  matter  here.  Is  gout  increasing  as 
a  disease  in  the  United  States?  Undoubtedly  it  is,  just  as 
rheumatism  appears  to  be  diminishing.  The  causes  undoubt- 
edly are  the  spread  of  luxury  from  the  vast  increase  of  wealth 
accumulated  in  private  hands,  the  great  increase  of  the  use  of 
malt  liquors  and  wines  as  beverages,  and  another  factor  not 
often  taken  into  account, — the  absorption  of  lead  into  the 
system,  this  coming  in  the  old  forms  of  drinking  water 
through  lead  pipes  and  the  various  other  forms  unseen  and 
unheard  of,  as  through  the  enamelled  inside  bands  of  our 
first-quality  hats,  especially  the  English  hats.  The  great  fac- 
tors in  lead  entering  the  system  to-day  are  the  general  uses 
of  the  metal  in  water-pipes,  in  beer-pumps  and  pipes,  in  soda- 
water  apparatus,  in  tinned  or  canned  food  products,  and  in 
the  free  use  of  lead  foils  in  tobacco  products  as  at  present  mar- 
keted. These  outrages  on  the  health  of  mankind  are  prevent- 
able, and  should  be  stopped  by  law  without  delay.     Haig 

431 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

thinks  lead  diminishes  the  alkahnity  of  the  blood  and  hence 
causes  gout.  I  believe  plumbism  is  a  neurosis,  and  the  pres- 
ence of  lead  in  the  system  undoubtedly  causes  this  neurosis, 
and  it  so  affects  tissue  metabolism  as  to  produce  gout,  going 
back  for  its  cause,  if  you  choose,  to  the  formation  of  the  uric 
acid  and  leukomaines  from  the  nuclein  of  the  blood-corpuscles. 
In  gout  of  the  intestines  particularly,  or  supposed  gout  of  the 
intestines,  be  very  careful  to  differentiate  it  from  lead  colic, 
and  remember  that  they  may  and  do  often  coexist.  In  your 
differentiation  do  not  fail  to  bear  in  mind  the  various  symp- 
toms of  appendicitis. 

The  interesting,  points  in  the  treatment  of  gout  are,  after 
all,  how  shall  we  advise  the  victims  of  chronic  gout  and  the 
victims  of  the  so-called  lithsemic  condition  to  live,  in  order 
that  they  may  have  the  most  comfort  and  get  the  most  out 
of  life,  not  only  in  its  enjoyments,  but  in  its  prolongation  to 
a  green  and  happy  old  age.  You  may  tell  your  patients  at 
once,  there  is  one  way  not  to  do  it,  and  that  is  "  to  eat,  drink, 
and  be  merry,"  and  to  endeavor  to  do  away  with  all  untoward 
consequences  by  taking  the  so-called  anti-gout  remedies, 
whether  they  come  from  their  regular  medical  attendants 
or  come  from  the  long  list  of  proprietary  remedies  seen  in 
every  drug-store.  Among  men  of  the  world  whom  gout  is 
pinching,  it  is  common  to  see  them  taking  Blair's  pills,  an 
English  preparation  of  reputation.  Colchicum  and  opium 
probably  are  ingredients,  and  give  temporary  relief.  Laville 
is  another  popular  remedy,  which  undoubtedly  owes  its  virtue 
to  colchicum.  I  do  not  care  what  such  remedies  contain,  and 
how  effective  they  may  be,  the  method  does  great  harm,  and 
invites  in  the  end  much  suffering  and  premature  death. 

Now,  as  to  water.  Judiciously  used,  I  believe  it  to  be  our 
greatest  weapon  in  fighting  gout,  particularly  chronic  gout. 
It  should  be  used  freely,  both  per  rectum  and  per  orem  and  in 
bathing.  Intestinal  lavage  I  look  upon  as  of  the  greatest 
benefit  in  the  treatment  of  the  lithsemic  or  gouty  condition. 
The  water  should  be  sterilized,  and  chloride  of  sodium,  one 
of  the  best  intestinal  antiseptics,  should  be  added  at  the  rate 

432 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

of  a  heaped  teaspoonful  to  n  pint.  This  may  be  given  on  re- 
tiring, as  much  as  the  large  bowel  will  tolerate,  and  heUl  as 
long  as  possible.  If  preferable,  during  an  hour  before  retiring, 
drink  a  quart,  more  or  less  of  water,  and  with  it  take  thirty 
grains  of  sodium  bicarbonate  should  there  be  a  tendency  to 
acifl  eructations.  I  particularly  recommend  sodium  here  and 
not  the  potassium  salt,  for  in  gout  the  kidneys  are,  we  kncnv, 
very  vulnerable,  and  potassium  is  more  irritating  to  the  kid- 
neys than  sodium.  If  there  be  no  need  for  the  sodium  on 
this  account,  take  from  five  to  ten  grains  of  salol  with  the 
water.  This  breaks  up  into  salicylic  acid  and  phenol  in  the 
upper  intestinal  tract,  and  is  antiseptic  and  increases  nitroge- 
nous elimination.  The  gouty  patient,  as  a  rule,  is  not  a 
thirsty  person,  and  few  drink  enough  water.  They  should 
drink  all  that  it  is  possible  for  them  to  take  and  be  comforta- 
ble. It  is  the  great  weapon  in  the  fight  against  the  gouty 
condition.  Where  it  is  possible  to  obtain  them,  the  natural 
alkaline  waters  are  most  useful,  and  of  these  the  Vichys  are 
the  best.  Wherever  we  can  get  a  good  alkaline  water  in  our 
own  country,  or  get  to  the  springs  to  use  them,  they  will 
prove  useful  if  taken  in  large  quantities. 

The  lithium  salts  have  long  been  recommended  by  Garrod 
and  others  as  solvents  for  uric  acid  and  the  urates.  In  my 
hands  they  have  never  shown  any  practical  effect  as  lithium. 
The  "  lithia"  waters  on  the  market  are  usually  good,  pure 
waters,  with  a  suspicion  of  lithium  in  them,  a  mere  suspi- 
cion, and  if  lithium  was  really  of  any  use  in  the  treatment 
of  gout  it  would  take  bottles  of  most  of  them  for  a  single 
dose.  They  come  nicely  put  up,  and  do  good  by  encouraging 
patients  to  drink  w^ater;  beyond  this  they  amount  practically 
to  nothing.  Carbonated,  they  are  aiders  of  digestion  and 
very  acceptable.  There  are  many  waters  of  other  brands  on 
the  market,  both  plain  and  carbonated,  some  of  them  very 
pure.  Here  is  their  mission :  they  give  good  pure  water  and 
encourage  the  drinking  of  it,  and  are  handy  for  travellers 
who  become  ill  by  constantly  changing  the  water  supply ;  and 
they  carry  off,  as  do  most  fluids  taken,  the  excess  of  nitroge- 
28  433 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

nous  waste,  which  retained  becomes  a  source  of  pabulum  for 
microbes  and  a  prominent  factor  in  auto-infection  and  auto- 
intoxication. This  use  of  water  in  gout  applies  most  particu- 
larly to  women,  who  are  great  sufferers  from  lithsemia,  and 
who  very  rarely  drink  water  sufficient  for  their  common 
needs,  much  less  as  a  remedial  measure. 

There  is  another  important  measure,  in  addition  to  this 
water  treatment  of  gout.  Now  and  again,  say  once  a  week 
or  once  a  fortnight,  give  a  small  dose  of  calomel,  sufficient 
to  stimulate  the  liver,  for  such  it  probably  does,  causing  it 
to  throw  out  an  extra  amount  of  bile  and  thus  antisepticize 
the  bowel.  There  is  generally  constipation  in  the  gouty, 
which  is  best  relieved  by  the  aperient  waters  before  the  morn- 
ing meal,  and  may  be  taken  daily  if  needed.  Any  of  the 
saline  purgatives  may  be  used  if  preferred. 

Now,  as  to  food.  For  reasons  before  given,  we  must  avoid 
in  a  great  measure  foods  rich  in  nitrogen,  for  if  on  this  score 
our  reasoning  is  not  yet  on  a  firm  foundation,  experience 
comes  to  our  aid  and  tells  us  much.  Do  not  forget  to  study 
your  patient.  Is  he  strong  and  vigorous,  or  is  he  weak  and 
failing,  and  what  idiosyncrasies  has  he  as  to  certain  articles 
of  diet?  Horatio  Wood  is  one  of  our  best  authorities  on 
diet,  as  he  is  on  many  other  matters.  He  says  there  is  no 
diet  for  gout;  it  is  diet  for  the  individual.  Sydenham  first 
warned  the  gouty  against  red  meats,  and  red  meats  may  give 
one  person  gout  and  cure  another;  that  is  to  say,  the  latter 
case  may  be  weak  and  puny  and  absolutely  in  need  of  the 
strength  only  to  be  derived  from  nitrogenous  food.  For  the 
same  reasons  one  may  require  starch  and  sugar  to  a  greater 
or  less  degree,  and  one  may  go  to  pieces  on  them  as  part  of 
the  diet.  A  milk  diet  may  be  necessary  for  some  cases  for  a 
longer  or  shorter  time,  and  even  reduced  milk  or  skim-milk 
or  other  milk  preparations,  as  koumiss  and  the  like.  As  to 
meats,  there  is  little  difference  really  in  the  amount  of  pro- 
teids  in  the  red  and  white  meats.  A  reference  to  the  article 
■on  diet  in  a  former  chapter  will  show  all  of  this  matter  in  a 
hv'iei  space.     Roast  chicken  is  nearly  as  strong  as  roast  beef, 

434 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

and  roast  turkey  is  well  up  to  roast  chicken,  whilst  roast 
goose  is  very  fat  and  a  little  lighter  in  nitrogen  than  either 
of  the  others.  The  gouty  patient  must  eat  less  in  (juantity, 
and  thus  cut  down  his  nitrogen.  Semi-starvation  must  be  his 
rule.  Overeating  is  a  habit  anyhow,  and  a  very  bad  habit, 
too.  Accustom  yourself  to  leaving  the  table  comparatively 
hungry  a  few  times,  and  the  inconvenience  soon  passes  away. 
We  all  eat  too  much. 

Now  as  to  fish  as  the  lighter  flesh  diet.  It  is  lighter  diet 
than  animal  flesh,  but  it  depends  on  what  kind  of  fish.  Salmon 
is  nearly  as  strong  as  roast  beef.  In  fact,  all  fish  are  com- 
paratively strong  in  nitrogen.  The  shellfish  are  weaker  and 
better  food  for  the  gouty.  A  reference  to  the  article  on  diet 
will  tell  the  fish  story.  As  I  have  said  before,  whilst  fish,  or 
at  least  many  of  them,  are  high  in  nitrogen,  they  are  lighter 
food  than  animal  flesh,  for  they  do  not  overload  the  blood 
with  waste  products  as  the  animal  foods  do,  and  the  blood 
sooner  clears  itself  of  the  waste  products  from  fish  than  of 
those  from  animal  food. 

Let  us  go  to  a  clinical  study,  and  by  this  I  think  we  can 
show  a  difference  in  the  efifect  of  animal  flesh  and  fish  diet. 
Intermitting  heart,  not  the  more  serious  irregular  heart,  is. 
as  we  all  know,  so  common  among  the  sufiferers  from  chronic 
gout  and  the  gouty  condition,  and  is  serious,  not  because  it 
is  in  itself  a  serious  condition,  but  only  as  to  the  ill  effect  it 
may  have  on  the  patient.  Some  never  know  they  have  it. 
Avhilst  others  are  very  unhappy  over  their  condition.  Brady- 
cardia and  tachycardia  come  under  the  same  head.  Here  an 
excess  of  nitrogen  in  the  food  and  the  overloading  of  the 
blood  with  waste  products  are,  I  think,  the  prime  factors  of 
causation.  Fish  diet  causes  much  less  of  this  overloading  of 
the  blood  with  waste  products,  and  hence  is  not  nearly  so  apt 
to  cause  arrhythmia  as  the  animal  flesh  diet,  for  the  alkalinity 
of  the  blood  is  not  so  much  lessened  by  it.  Toxines  are  more 
apt  to  develop  from  such  food,  and  these  in  the  intestines 
cause  such  functional  heart  troubles.  They  overload  the 
stomach  usually,  or  rather  cause  the  stomach  hard,  quick 

435 


FORTY   YEARS    IN    THE   MEDICAL    PROFESSION 

work  to  get  rid  of  them,  and,  the  blood-vessels  being  over- 
loaded-, arrhythmia  occurs.  Excess  of  blood-pressure  is  also 
a  factor,  and  this  we  usually  have  in  the  gouty,  hence  the 
gouty  man  is  more  apt  than  the  healthy  man  to  suffer  from 
functional  heart  disturbances  after  eating  and  drinking,  and 
particularly  after  the  use  of  tobacco.  These  troubles  can  be 
classed  among  the  neuroses  pure  and  simple.  Again  we  may 
ask  the  question,  Is  gout  a  neurosis? 

Some  teachers  have  condemned  a  diet  composed  chiefly  of 
carbohydrates  as  of  more  injury  to  the  gouty  than  a  diet 
chiefly  of  nitrongenous  food.  The  reasoning  is  that  too  much 
carbohydrates  may  take  so  much  oxygen  for  their  oxidation 
that  there  will  be  a  deficiency  for  the  changing  of  the  uric 
acid  into  urea,  and  thus  leave  the  uric  acid  in  the  blood.  Too 
much  fat  may  do  the  same  thing  in  the  same  way.  Thus  the 
accumulation  of  winter  fat  is  apt  to  give  us  spring  gout,  a 
favorite  reason  for  it. 

Now  let  us  take  up  alcohol  and  its  effect  on  the  gouty. 
Alcohol,  nicotine,  and  morphine  all  diminish  temperature^ 
the  first  two  by  relaxing  the  blood-vessels  and  increasing  per- 
spiration, and  the  later  by  preventing  all  glandular  and  molec- 
ular activity.  Alcohol  in  any  form,  ether,  chloroform,  and 
the  like,  all  reduce  the  alkalinity  of  the  blood,  and  are  innately 
bad  in  gout.  Alcohol  also  undoubtedly  reduces  the  bacteri- 
cidal action  of  the  blood,  and  is  bad  for  that  reason  in  gout.  A 
sober  guinea-pig  will  withstand  six  times  the  dose  of  toxines 
that  a  drunken  guinea-pig  will.  Alcohol's  affinity  for  oxygen, 
of  which  it  robs  the  blood,  causes  the  loading  of  the  blood  with 
toxines,  which  result  from  imperfect  oxidation  of  the  tissues, 
and  thus  we  see  hw  the  drunken  guinea-pig  succumbed  before 
the  sober  guinea-pig.  An  excesss  of  alcohol  is  particularly 
bad  for  the  gouty.  It  bloats  and  gives  a  false  look  of  health. 
This  bloat  is  an  abnormal  tissue,  an  unbalanced  tissue,  which 
should  have  been  consumed  by  the  vital  processes  in  health 
by  oxidation,  but  the  alcohol  has  used  up  this  oxygen  and 
the  normal  oxidation  of  the  fat  did  not  go  on,  and  hence  it  is 
stored  up  as  useless,  harmful,  unbalanced  tissue,  and  the  vic- 

436 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

tim  is  an  unhealthy  fat  person,  his  car-marks  being  plainly 
visible,  for  he  carries  his  own  sign.    He  is  a  bloat. 

Alcohol  goes  to  acid  in  its  digestion,  and  thus  reduces  the 
alkalinity  of  the  blood.  Sugar  with  alcohol  increases  its 
power  of  reducing  the  alkalinity  of  the  blood ;  so  beware ! 
take  your  whiskey  straight,  not  as  a  cocktail.  The  sugar  in 
wines  makes  them  more  objectionable,  for  it  starts  all  sorts 
of  intestinal  fermentations  and  decreases  the  alkalinity  of  the 
blood.  The  best  drink  for  the  gouty  is  water  or  milk.  Of 
spirits,  a  pure  California  brandy,  with  no  coloring-rnatter, 
is  best,  and  next  to  this  is  Scotch  whiskey,  because  it  is  free 
from  sugar.  American  whiskey  is  a  good  drink,  except  that 
the  sugar  coloring-matter  is  objectionable.  Of  wines,  I  should 
object  to  all  but  a  good,  sound  claret,  and  that  well  diluted. 
Sugar  in  claret  is  a  horror  in  any  form,  and  those  using  it 
not  only  spoil  a  good  wine,  but  deserve  the  horrors  of  diges- 
tive nightmare.  If  one  must  have  a  sparkling  wine,  use  the 
Moselles  rather  than  the  champagnes,  unless  the  latter  are 
inky  dry.  The  malt  liquors  are  poison  to  the  gouty,  and 
should  under  no  consideration  be  indulged  in.  Lager  beer 
has  only  three  per  cent,  of  alcohol,  but  it  will  not  do.  In  these 
malt  drinks  we  have  alcohol  and  sugar  mixed,  and  they  are 
highly  acid.  That  is  all  there  is  about  it.  They  will  not  do 
for  the  gouty  man  or  woman.  Sweet  cider  and  sweet  perry 
(pear  cider)  are  not  particularly  gouty,  but  when  fermenta- 
tion has  passed  to  the  acid  stage  they  are  objectionable. 
The  basis  of  the  cider  cure  of  gout,  often  used  in  France, 
is  just  this :  the  juice  contains  much  potash,  and  this  acts 
by  reducing  the  acid  state  of  the  blood,  just  as  the  potash 
in  lemon- juice  does  in  the  lemon- juice  rheumatism  treat- 
ment. 

Shall  we  avoid  the  carbohydrates  in  gout?  That  depends 
upon  the  individual.  It  is  nonsense  to  lay  down  absolute 
rules  for  numerous  patients.  One  living  on  carbohydrates 
to  a  greater  or  less  extent  may  have  constant  acid  dyspepsia 
and  auto-intoxication,  particularly  if  sugar  be  associated  with 
them.     If  either  disagree,  avoid  them  as  much  as  possible. 

437 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

For  sugar,  saccharin  or  diabetin  may  be  substituted  now  and 
again.-  Saccharin  is  antiseptic,  and  may  thus  interfere  with 
digestion  and  cause  dyspepsia.  It  renders  the  urine  acid.  As 
a  rule,  gouty  people  who  have  not  ruined  their  digestion  can 
take  carbohydrates  with  impunity,  and  they  agree  with  them. 
If  they  do  not  agree,  they  probably  interfere  with  the  com- 
plete metabolism  of  the  albuminoids,  and  one  or  the  other 
must  be  cut  off  to  a  certain  extent,  or  altogether ;  and  so  with 
fats.  If  they  agree,  they  can  be  taken  in  moderation,  provided 
there  are  no  other  contraindications.  If  the  kidneys  are  in- 
volved and  albuminuria  appears,  use  fats  as  a  rule.  They 
check  the  waste  of  the  albumin,  and  so  do  the  carbohydrates, 
for  they  are  only  diluted  fats.  The  kidney  troubles  in  gout 
are  a  common  and  serious  complication,  and  when  the  pa- 
tient can  endure  it  for  a  time,  milk  diet  may  be  called  for, 
and  even  skim-milk  diet,  or  buttermilk,  a  by-product  of  cream. 
Remember,  one  patient  may  thrive  on  such  diet,  another  may 
endure  it,  whilst  a  third  may  sink  under  it.  Milk  is  a  normal 
alkaline  complete  food.  Fresh  breads  are  microbic  food, 
and  usually  disagree  in  gout.  Toasted  and  stale  breads  are 
better.  Avoid  all  foods  causing  fermentative  dyspepsia  and 
those  that  may  cause  indigestion  of  any  kind,  or  any  that 
might  cause  ptomaine  poisoning;  they  each  probably  have 
their  specific  pathogenic  germ.  Now  and  then  a  patient  may 
thrive  best  on  the  diet  for  diabetes  mellitus,  one  of  the  conge- 
ners of  gout,  but  such  cases  are  rare. 

Now,  an  important  question  comes  up :  what  about  the 
acid  vegetables  and  fruits?  I  think,  as  a  rule,  they  may  be 
used,  watching  the  effect  on  the  individual.  Strawberries  are 
forbidden  in  gout  by  most  physicians  on  account  of  their  acid- 
ity. Linnaeus,  who  suffered  from  gout  most  of  the  time, 
said  he  was  only  well  in  strawberry  time,  when  he  ate  largely 
of  them.  Like  the  lemon,  their  acidity  may  be  only  apparent, 
not  real,  and  they  may  render  the  blood  alkaline,  not  acid. 
Their  juice  is  probably  germicidal,  like  that  of  many  other 
fruits.  It  is  not  impossible  they  may  have  an  effect  of  pro- 
ducing hippuric  and  benzoic  acids,  thus  rendering  the  uric 

438 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

acid  soluble.  Wc  take  caljljag'c,  liriissels  sprouts,  turnips, 
celery,  tomatoes,  s])iiiach,  asparagus,  and  such  vegetables, 
not  forgetting  rhubarlj,  so  grateful  in  the  early  spring.  It 
is  doubtful  if  rhubarb  has  any  effect  on  the  formation  or  the 
elimination  of  uric  acid,  although  it  contains  some  oxalic 
acid.  Its  mineral  matter  in  some  way,  I  doubt  not,  is  useful, 
and  I  do  not  believe  it  ever  caused  a  serious  fleposit  of  oxa- 
lates in  the  urine  or  tissues.  The  same  may  be  said  of  spin- 
ach, tomatoes,  asparagus,  cabbage,  and  such  vegetables ;  they 
probably  all  contain  oxalic  acid.  According  to  recent  inves- 
tigations the  mineral  matters  of  all  of  these  vegetables  act 
chemically  and  prevent  the  deposition  of  gouty  matter  in  the 
tissues,  and  are  the  best  remedies  to  prevent  such  deposits. 
I  believe  this  to  be  true;  this  is  the  way  in  which  nature 
solves  such  problems,  and  for  such  uses  they  have  been  given 
to  man. 

I  know  of  no  vegetable  which  the  gouty  person  can  use 
freely  equal  to  green  corn.  The  small  amount  of  maizenic 
acid  it  contains  has  a  good  effect  and  does  not  excite  meta- 
bolic activity  of  tissues,  nor  does  the  corn  as  a  vegetable  to 
a  large  degree,  and  by  its  bulk  it  leads  to  a  healthy  condition 
of  the  bowels  where  obstinate  constipation  is  so  often  an 
unpleasant  factor.  In  soup  with  milk  it  may  be  used  every 
day  in  the  year,  and  this  makes  an  ideal  dish  for  the  lithaemic 
sufferer.  Do  not  use  much  salt  with  the  corn,  as  the  syno- 
vial fluids  have  great  affinity  for  salt,  and  you  thus  may 
check  the  formation  of  the  soluble  sodium  biurate.  Zea, 
corn-silk,  acts  as  a  diuretic,  and  I  believe  is  useful  in  chronic 
gout,  especially  in  cases  where  the  bladder  is  irritable.  It 
is  a  diuretic,  increasing  arterial  pressure,  and  should  be  given 
in  large  quantities  of  hot  water  every  few  hours. 

Cheese  is  highly  nitrogenous  and  must  be  used  with  cau- 
tion, but  I  see  no  reason  why  a  gouty  man  cannot  take  a 
morsel  now  and  again  to  give  zest  to  a  cracker  or  possibly  a 
mild  salad.  Eggs  are  a  common  and  useful  article  of  diet, 
for,  if  fresh,  they  are  absolutely  sterile  food  and  perfectly 
safe  as  far  as  germ  infection  goes.     They  are  said  to  be  of 

439 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

an  alkaline  tendency  and  to  set  the  urinary  secretion  alka- 
line. If  a  gouty  patient  is  weak  and  needs  proteid  diet,  eggs 
are  most  useful.  If  the  patient  be  strong  and  vigorous,  use 
the  yolks  freely,  and  discard  the  white,  as  it  is  too  strong, 
being  typical  albumin.  If  you  know  your  gouty  patient  to 
be  the  victim  of  contracted  kidney,  interstitial  nephritis,  be 
very  careful  of  concentrated  nitrogenous  food,  especially  those 
like  red  meats,  and  the  white  of  eggs,  which  leave  more  or 
less  waste  products,  which  require  much  oxygen  to  eliminate 
them  from  the  blood. 

Ursemic  convulsions  may  be  looked  for  in  such  cases,  and 
I  sometimes  think  the  cause  is  more  the  toxines  developed 
from  such  food  than  from  the  other  causes  usually  assigned. 
Such  cases  may  be  infantile  convulsions  over  again.  In  these 
renal  cases  use  the  amount  of  urine  flowing  as  the  barometer. 
If  you  are  ordering  your  patient  a  large  quantity  of  water, 
of  course  it  goes  off  rapidly  by  the  kidneys.  If  the  excess 
of  the  normal  amount  is  still  too  high,  check  the  blood- 
pressure  by  nitroglycerin,  and  possibly  save  your  patient  from 
cerebral  hemorrhage  or  some"  accident  always  pending  from 
the  impaired  condition  of  the  arteries  of  such  patients.  Under 
these  conditions  asthmatic  troubles  are  apt  to  show  them- 
selves, and  may  be  purely  of  a  neurotic  origin  connected  with 
the  gouty  condition,  and  so  may  sore  throat,  generally  of  an 
erythematous  nature,  although  this  latter  trouble  I  think  is 
common  in  both  acute  and  chronic  gout,  as  are  skin  affec- 
tions generally  of  an  eczematous  nature. 

Gouty  headache  is  common,  and  usually  alternates  with 
the  before-mentioned  annoyances.  It  usually  is  most  annoy- 
ing on  first  waking  in  the  morning,  and  is  usually  a  hot, 
burning  pain  through  and  back  of  the  eyes.  Those  who  have 
been  victims  of  migraine,  or  sick  headache,  up  to  the  age  of 
forty-five  usually  are  the  sufferers  from  gouty  headache  after 
that  age.  High  blood-pressure  is  a  factor  in  gouty  headache, 
and  the  remedy  is  plain, — lower  it.  This  headache  usually 
passes  off  after  a  cold  bath  and  a  rub  to  the  head  and  shoul- 
ders, if  the  patient  is  robust  and  reacts  well.     A  light  break- 

440 


FORTY    YEARS    IN    THE    MEDICAL    PROEESSION 

fast  and  a  walk  in  the  fresh  air  complete  the  cure.  Sick 
headache,  as  a  rule,  passes  off  only  with  the  setting  sun.  In 
chronic  gout  medicinal  remedies  should  only  be  used  in  acute 
attacks,  or  subacute  attacks,  marked  with  pain.  I  believe  the 
best  remedy  is  the  salicylates  of  sodium  or  strontium,  in 
connection  with  colchicum ;  they  both  do  better  when  used 
together.  The  salicylates  are  antipyretic  and  possibly  anti- 
periodic  and  germicidal.  They  possibly  control  pain  through 
their  influence  on  the  vasomotor  system  and  by  causing  the 
elimination  of  urea  and  uric  acid.  If  the  patient  have  albu- 
minuria, be  careful  with  the  salicylates;  better  use  colchicum 
alone  most  of  the  time  or  with  the  iodides.  Colchicum  may 
increase  the  elimination  of  both  urea  and  uric  acid,  and  may 
do  this  probably  through  its  cholagogue  effect  on  the  liver 
and  thence  through  the  peptones  from  the  food.  Iodide  of 
potassium  may  he  given  with  colchicum.  With  kidney  lesions, 
strontium  is  to  be  preferred  with  colchicum.  This  is  against 
Haig's  reasoning,  if  we  wish  to  keep  down  the  arthritis,  but 
in  practice  it  acts  well,  especially  in  the  feeble,  with  marked 
arteriosclerosis  in  any  form.  As  I  have  before  stated,  I 
usually  prefer  a  capsule  containing  methyl  salicylate  and  col- 
chicin,  and  I  especially  prefer  this  combination  if  I  have  to 
use  salicylic  acid  when  the  patient  has  albuminuria,  for  if 
there  is  any  difference  in  their  irritating  action  on  the  kidneys, 
I  think  the  methyl  salicylate  the  least  irritating  as  between  it 
and  the  synthetic  compounds. 

Professor  James  Tyson,  one  of  our  best  authorities,  prefers 
the  salicylates  in  the  treatment  of  gout.  I  think  a  Turkish 
bath  at  frequent  intervals  is  one  of  the  best  eliminators  in 
the  treatment.  The  best  plan,  after  all  has  been  said,  is  semi- 
starvation,  whether  direct,  by  cutting  down  the  amount  of 
food,  or  indirect,  by  active  exercise,  adding  to  this  semi- 
starvation  the  free  use  of  water;  and  the  Turkish  bath  is 
one  of  the  best  ways  by  which  to  use  the  water.  By  these 
means  we  best  guard  the  kidneys  from  degeneration  and  save 
the  arteries  from  the  inroads  of  arteriosclerosis.  By  such 
means,  with  proper  clothing,  proper  environment,  and  changes 

441 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

of  climate  when  possible,  leading  a  quiet,  sober,  and  active 
life,  the  activit)^  being  ganged  by  the  physical  condition,  the 
gouty  individual  may  keep  his  Nemesis  at  bay  and  reach  a 
green  old  age. 

Ointments  of  the  salicylates  are  undoubtedly  useful  for 
anointing  the  joints,  and  the  same  may  be  said  of  the  oil  of 
gaultheria,  used  as  a  paint  and  frequently  applied. 

As  yet  there  is  little  favorable  to  report  in  regard  to  the 
use  of  piperazine  in  gout.  I  am  sure  of  one  thing:  it  is  of 
great  use  in  those  cases  where  there  is  a  tendency  to  the  de- 
posit of  the  urates  in  the  kidneys,  producing  frequent  attacks 
of  renal  colic.  I  would  always  give  it  in  these  cases  for  its 
effect  on  the  diathesis,  for  its  local  effect  on  the  stone  in  the 
kidney,  and  after  it  has  reached  the  bladder.  I  am  satisfied 
that  a  five-grain  dose  three  times  a  day  is  the  best  remedy 
in  all  forms  of  muscular  rheumatism  or  gout.  It  is  sup- 
posed to  act  as  a  solvent  to  uric  acid.  Do  not  give  acids  in 
food  or  medicine  whilst  the  patient  is  taking  piperazine. 

Pichi  is  a  shrub  found  growing  in  Chile  and  Peru.  It  has 
greenish-blue  leaves  and  a  balsamic  odor.  Its  active  principle 
is  in  its  balsamic  resin.  Dr.  Hervey  W.  Whitaker,  of  Colum- 
bus, Ohio,  says  it  is  a  strong  cholagogue  and  has  a  stimu- 
lating effect  on  all  mucous  membranes.  It  is  a  valuable 
remedy  in  gall-stones.  In  the  uric  acid  diathesis,  gout, 
chronic  rheumatism,  sciatica,  muscular  rheumatism,  and 
gouty  headache  it  is  of  great  value.  Its  remedial  action  far 
excels  that  of  the  salicylates  in  such  troubles.  Uric  acid  for- 
mations rapidly  disappear  from  the  urine  under  its  use,  and 
the  general  condition  improves.  It  acts  through  the  liver, 
being,  I  suppose,  a  strong  cholagogue.  Whittaker  thinks  its 
active  principle  effects  some  combination  in  the  circulation 
favorable  to  the  solution,  excretion,  and  elimination  of  the 
products  of  metabolism,  which  a  sluggish  liver  would  other- 
wise be  incapable  of  transforming.  It  is  the  best  bitter  tonic 
in  chronic  alcoholism,  and  is  most  useful  in  the  cystitis  of 
enlarged  prostate,  and  in  gout  of  the  intestines  it  is  said  to 
be  superior  to  the  salicylates.     It  is  useful  in  jaundice  and 

44-2 


FORTY    YEARS    JN    TMK    MF^DICAL    PROFESSION 

cirrhosis  of  the  hver.  The  iluid  extract  is  tlie  best  prepara- 
tion. It  will  not  mix  with  water,  owing  to  its  resinous  prop- 
erties, except  yon  add  a  small  f|uaiitity  of  an  alkali,  say,  twenty 
to  thirty  grains  sodium  bicai^honate  to  the  ounce.  The  dose 
is  a  half-teas{)oonful  every  four  hours,  more  or  less.  A  good 
mixture  is  glycerin  one  ounce  and  fluid  extract  pichi  one- 
half  ounce.  A  teaspoonful  and  a  half  in  water  is  a  dose.  It 
may  also  be  given  in  powder,  in  a  capsule  or  a  tablet. 

Thyroid  extract  and  gout  and  rheumatism,  from  clinical 
experience  now  accumulating,  give  opportunity  for  interest- 
ing study.  Horatio  Wood  reports  four  cases  in  which  gout 
or  rheumatism  followed  the  administration  of  thyroid  ex- 
tract. He  has  as  yet  drawn  no  conclusions  from  these  cases 
for  publication.  Dr.  B.  K.  Rachford,  of  Cincinnati,  Ohio, 
has  also  called  attention  to  the  action  of  thyroid  extract  in 
producing  gout.     Rachford  sums  up  as  follows : 

1.  Attacks  of  arthritic  gout  are  associated  with  the  excre- 
tion of  an  excess  of  the  alloxuric  bodies  in  the  urine. 

2.  Thyroid  feeding  will  increase  the  excretion  of  the  allox- 
uric bodies  in  the  urine,  and  will  produce  an  acute  arthritis 
in  a  patient  suiTering  from  chronic  rheumatic  gout. 

A  third  fact  he  adds  :  The  menstrual  period  in  \vomen  often 
precipitates  an  attack  of  gouty  inflammation,  and  may  be 
called  menstrual  gout.  Now^  at  the  menstrual  period  there  is 
a  hyperacidity  of  the  thyroid  gland,  and  thus  we  may  be  led 
to  suppose  that  the  thyroid  secretion  has  something  to  do 
wath  the  abnormal  body  chemistry  which  is  coincident  with 
these  gouty  attacks. 

These  are  valuable  and  interesting  facts,  and  may  in  the 
end  give  some  clue  to  the  true  pathology  of  gout.  In  giving 
thyroid  we  produce  a  decided  loss  of  weight,  due  in  part  to  a 
destruction  of  the  nitrogenous  tissues,  but  chiefly  to  the 
wasting  of  the  fats.  One-sixth  loss  is  from  the  former  and 
five-sixths  from  the  latter.  The  eftect  here  is  to  interfere 
wath  the  tissue  balance  and  to  lower  the  fuel  values  much 
more  than  the  flesh-formers.  Somewhere  between  these  com- 
plex processes  having  to  do  with  tissue-building  and   fuel 

443 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

values  must  be  the  cause  of  gout,  and  this  is  where  it  is  now 
generally  located,  and  is  expressed  by  a  faulty  metabolism. 
As  age  comes  over  us  we  grow  decrepit,  day  by  day  and  more 
and  more  the  victims  of  disarranged  and  abnormal  meta- 
bolism, and  so  we  do  in  gout,  and  after  all,  what  is  gout  but 
old  age,  premature  if  in  the  young,  fully  ripened  if  we  have 
reached  the  time  of  the  "  sere  and  yellow  leaf"?  This  being 
the  case,  the  remedy  would  appear  to  be,  not  thyroid  extract, 
which  pulls  down  and  destroys,  but  the  extracts  probably  of 
those  glands  which  are  rather  builders  up,  and  the  flesh  and 
extracts  not  of  old  animals,  but  of  the  younger,  wherein  we 
might  hope  to  find  that  of  which  old  age  has  deprived  us,  and 
the  taking  of  which  might  in  some  degree  or  another  rein- 
vigorate  us.  Such  was  the  notion,  probably,  of  the  late  illus- 
trious Brown-Sequard. 

In  Europe  the  good  livers,  as  they  reach  the  age  when  gout 
begins  to  nag  them,  are  accustomed  to  take  the  cure,  as  they 
designate  it,  yearly.  The  cure  is  nothing  more  than  a  rest 
of  the  digestive  and  other  organs,  with  copious  washings  out 
of  the  system  with  water,  to  carry  off  the  accumulated  ni- 
trogenous wastes  of  the  system.  The  cure  generally  con- 
sumes a  period  of  six  weeks,  and  is  a  rational  way  of  letting 
up,  whether  the  taker  is  a  high  roller  or  merely  a  good  fellow, 
or  a  hard  worker  in  professional  or  business  life,  or  a  woman 
temporarily  blase  from  the  exactions  of  the  social  whirl. 
Carlsbad  is  the  typical  resort  for  the  cure.  Would  we  had  a 
Carlsbad  in  the  United  States!  We  should  have;  we  have 
the  making  of  such  at  Saratoga  or  in  the  Virginia  mountains, 
and  many  other  places  where  we  have  the  waters.  The  trouble 
is,  that  in  this  country  people  look  upon  all  such  resorts  as 
a  place  in  which  to  dissipate,  rather  than  to  rest.  We  are 
improving  in  this  respect,  and  soon,  I  have  no  doubt,  we  shall 
have  an  American  Carlsbad,  where  the  free  American  citizen 
will  allow  himself,  under  surveillance,  at  least  long  enough 
to  wash  away  his  gout  along  with  his  other  grievous  sins. 
At  the  same  time,  the  hotel  men  and  boarding-house  keepers 
must  be  absolutely  restricted  in  their  rapacity,  for  the  serving 

444 


FORTY   YEARS    IN    THE   MEDICAL    PROFESSION 

of  improper  food  and  drink  must  be  made  impossible  at  tlie 
American  Carlsbad,  as  it  is  at  the  German  Carlsbad.  The 
best  we  can  do  to-day  is  to  visit  the  various  sanatoria.  There 
are  many  well-appointed  ones  in  the  country,  but,  as  a  rule, 
they  are  expensive  and  are  not  by  any  means  the  Carlsbad  we 
are  hoping  for  and  looking  for. 

Should  you  go  to  Carlsbad  fairly  well  and  strong,  wishing 
to  reduce  your  weight  and  get  rid  of  gouty  aches  and  pains, 
3^ou  would  visit  a  local  physician  of  reputation  and  present 
your  letter  from  your  regular  professional  adviser.  Under 
the  care  of  the  local  physician  you  would  probably  take  a 
course  about  as  follows :  In  the  morning  get  up  at  half -past 
five  o'clock  and  be  at  the  proper  spring  at  six  o'clock.  Take 
one  glass  of  water  and  move  about  quietly  for  fifteen  minutes, 
at  the  end  of  which  time  take  another  glass  and  keep  in  mo- 
tion. Continue  this  course  until  you  have  taken  in  all  five 
glasses  of  water.  After  the  last  glass  has  been  taken,  continue 
to  walk  quietly  for  one  hour.  Now  go  to  breakfast,  which 
will  probably  be  composed  of  three  pieces  of  German  zwieback, 
one  portion  of  boiled  ham  entirely  lean,  a  cup  of  tea  with 
milk,  but  with  no  sugar.  After  this  the  kidneys  and  bowels 
will  probably  act  freely.  Until  eleven  o'clock  walk  briskly 
over  the  hills.  Hill-climbing  will  be  strongly  urged  upon 
you  by  the  doctor ;  and  after  this,  say,  from  eleven  to  twelve 
o'clock,  Swedish  gymnastics,  and  frequently  after  this  a  Turk- 
ish bath  and  massage.  One  o'clock  is  the  mid-day  hour  for 
dinner,  which  is  frugal  and  plain :  No  soup ;  boiled  fish  only, 
with  lemon-juice;  your  choice  of  lamb,  veal,  or  chicken, 
roasted,  with  little  or  no  fat;  no  potatoes,  carrots,  or  peas 
are  allowed,  but  you  may  eat  string-beans  or  lettuce  with 
lemon- juice  only,  no  vinegar  nor  oil.  For  dessert  a  compote 
without  sugar.  The  only  drink  allowed  is  a  half-bottle  of 
sound  red  wine.  After  dinner,  walk  until  four  o'clock  p.m., 
the  walking  to  be  done  rather  quietly  and  slowly,  with  little 
or  no  hill-climbing.  You  }]iust  keep  moving  constantly  until 
six  o'clock,  when  tea  or  supper  is  ready.  The  idea  is  not  to 
sit  down  and  rest  at  all  if  you  have  the  strength  to  continue 

445 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

moving.  Keep  in  the  open  air.  The  supper  will  consist  of 
either  cold  lamb,  cold  mutton,  chicken,  or  ham,  with  as  little 
of  fat  as  possible.  With  this  you  will  be  served  with  three 
pieces  of  German  zwieback  and  a  half -bottle  of  some  of  the 
effervescing  waters.  Go  to  bed  not  later  than  nine  o'clock 
P.M.,  having  smoked  not  more  than  one  mild  cigar,  should 
3^ou  happen  to  be  a  smoker.  You  are  constantly  enjoined  to 
drink  plenty  of  water.  The  shortest  cure  is  three  weeks  at 
Carlsbad,  and  the  keeping  up  of  the  diet  and  exercise  rigidly 
for  three  weeks  longer,  should  you  leave  the  Spa.  For  the 
gouty,  for  the  high  liver,  for  the  gourmand,  this  is  a  rational 
treatment  once  in  a  year  surely,  and  doubtless  prolongs  life 
and  the  comfort  of  living.  For  six  weeks  they  do  penance 
and  eat  only  to  live;  for  the  remainder  of  the  year  they  enjoy 
themselves,  more  rationally,  at  least,  by  this  abstinence,  in 
the  blissful  occupation  of  living  to  eat. 

DIABETES  MELLITUS. 

Diabetes  mellitus  is  a  condition  where  there  is  an  excessive 
secretion  and  discharge  of  urine,  where  there  must  be  at  least 
three  parts,  and  maybe  as  high  as  ten  parts,  in  a  thousand 
of  saccharine  matter  in  the  blood,  and  secondarily  in  all  the 
organs,  secretions,  and  excretions  of  the  body,  and  is  due  to 
some  derangement  of  the  glycogenic  function  of  the  liver; 
or  defect  in  the  assimilative  processes  may  overload  the  blood 
with  sugar  and  cause  it  to  appear  in  the  urine.  Over-stimu- 
lation of  the  system  by  eating  and  drinking  and  other  ex- 
cesses may  cause  it  temporarily;  irritation  of  the  floor  of 
the  fourth  ventricle  and  some  other  parts  of  the  brain  and 
nervous  system  may  cause  it,  coming  probably  through  a  dis- 
turbed vasomotor  action.  Defective  assimilation  may  cause 
it  by  failing  to  properly  use  the  sugar  of  the  system  as  pro- 
duced, and  thus  send  it  off  by  the  urine.  Remember  that 
cane-sugar,  called  sometimes  saccharose,  or  sucrose,  must  be 
converted  into  glucose,  or  grape-sugar,  before  it  can  be  ab- 
sorbed or  assimilated,  and  hence  glucose  is  a  predigested 
sugar,  a  predigested  carbohydrate. 

446 


FORTY   YEARS    IN    THE   MEDICAL   PROFESSION 

Sugars  are  crystalHzablc  carlxjhydrates,  in  which  oxyj^en 
and  hych^ogen  are  present  in  the  proper  proportions  to  ff^rm 
water.  As  food  they  have  the  same  use  as  starches,  and 
starches  to  be  assimilated  are  first  converted  into  dextrin, 
which  is  a  gummy  mass  obtained  by  heating  starch  to  about 
400°  F.,  or  into  glucose  and  some  alcohol.  Glycogenic  mat- 
ter, called  so  by  its  discoverer,  the  great  French  physiologist, 
Claude  Bernard,  is  that  substance  in  the  system  which  is  con- 
sumed in  muscular  contraction,  and  this  is  its  use,  or  one  of 
its  chief  uses.  The  carbohydrates  furnish  this  chiefly,  al- 
though some  may  come  from  the  nitrogenous  foods.  The 
more  the  muscles  are  used  the  larger  they  become,  a  familiar 
illustration  of  which  are  the  muscles  of  the  trained  athlete, 
and  there  must  be  plenty  of  nitrogen  in  the  system  to  feed 
them,  and  plenty  of  glycogen  to  furnish  the  fuel,  the  residue 
going  off  as  urea.  Now,  observing  diabetics,  we  see  them 
sometimes  going  rapidly  to  a  decline,  because  in  such  cases 
the  glycogenic  matter  runs  out,  runs  away  by  the  urine,  and 
they  are  compelled  to  get  too  much  of  their  fuel  from  their 
nitrogenous  tissues,  and  are  burned  up  to  furnish  the  fuel 
to  the  muscles  the  glycogen  should  have  furnished.  The 
sorry  victim  of  this  condition  must  soon  succumb.  He  is 
starving  to  death.  It  is  in  these  cases  we  are  accustomed 
to  find  in  the  urine  acetone,  diacetic  acid,  beta-oxybutyric 
acid,  and  such  substances,  being  formed  from  the  decompo- 
sition of  the  albumin  of  the  body,  and  not  from  the  albumin 
taken  as  food.  The  invalid  is  existing  by  consuming  his 
owai  nitrogenous  tissues,  supplying  force  to  his  muscles  by 
burning  them  for  fuel. 

The  lamented  and  genial  W^illiam  R.  Travers  was  in  the 
last  years  of  his  life  a  diabetic.  Near  the  end  he  rapidly  failed 
from  this  consuming  of  the  nitrogenous  tissues,  and.  as  he 
expressed  it,  he  was  "  burning  the  candle  at  both  ends,  and 
was  devilish  near  the  middle." 

The  pathogenic  germ  of  tuberculosis  is  particularly  prone 
to  attack  diabetics  under  thirty  years  of  age,  and  my  experi- 
ence leads  me  to  believe  they  rapidly  consume  their  nitroge- 

447 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

nous  tissues  from  a  lack  of  gl3'X0genic  matter  so  necessary  to 
robust  health.  An  interesting  point  here  is,  do  the  tubercle 
bacilli  have  any  effect,  direct  or  indirect,  on  the  formation 
or  improvident  destruction  of  the  glycogenic  matter?  An- 
other point :  the  treatment  of  such  cases,  whether  tubercu- 
lous or  not,  demands  the  strongest  nitrogenous  and  fatty 
diet,  carefully  watching  the  effect,  and  the  question  comes  in 
to  vex  us,  whether  or  not  we  must  give  a  liberal  amount 
of  carbohydrates  too,  as  they  furnish  most  of  the  glycogen 
to  the  system.  We  must  surely  at  least  test  their  tolerance 
of  the  carbohydrates  and  alcohol.  I  have  here  given  the 
modus  operandi  of  the  devastation  even  unto  death  produced 
by  this  loss  of  glycogen,  which  at  the  temperature  of  the  body 
is  converted  into  glucose  and  passes  off  by  the  urine,  pro- 
ducing nothing  more  nor  less  than  the  disease  we  call  diabetes 
mellitus.  There  is  probably  in  the  system  a  glycogenic  fer- 
ment which  causes  this  change  of  the  glycogen  into  glucose. 
What  it  is  we  do  not  know.  Pancreatic  lesions  are  found  in 
many  cases  of  diabetes  mellitus,  but  no  conclusions  have  yet 
been  drawn  from  such  lesions.  In  some  cases  the  nervous 
element  may  predominate;  in  others  there  are  disarrange- 
ments of  the  digestive  organs,  caused  possibly  by  hepatic  or 
pancreatic  lesions ;  and  again,  we  see  cases  where  we  can  set 
our  seal  on  no  lesion  or  important  function  of  any  organ. 

We  have  shown  the  uses  of  glycogen  in  the  system ;  it  may 
be  well  to  see  how  it  gets  into  the  system,  in  order  to  under- 
stand at  least  something  about  the  disease  we  are  consider- 
ing. Carl  von  Noorden  has  probably  given  us  the  best  article 
on  Diabetes  Mellitus  up  to  this  present  time,  and  what  I  am 
about  to  say  concerning  the  causes,  physiology,  etc.,  is  largely 
taken  from  his  article,  the  use  of  which  I  beg  leave  to  ac- 
knowledge. After  all,  much  of  it  is  mere  conjecture,  but  it 
looks  to  me  as  though  in  many  particulars  he  was  getting 
near  the  truth.  Glycogen  is  a  polysaccharid,  and  must  be 
converted  into  a  soluble  carbohydrate  before  it  can  be  ab- 
sorbed. Diastase  is  the  ferment  to  cause  this  conversion, 
and  gives  us  from  starch,  amidulin,  erythrodextrin,  achro- 

448 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

odextrin,  isomaltose,  and  maltose.  Now,  as  these  pass  into 
the  intestinal  wall  and  portal  vein,  they  are  almost  entirely 
converted  into  grape-sugar.  Dextrin  and  maltose  are  also 
converted  into  glucose  when  taken  in  food  or  drink.  Cane- 
sugar  is  a  disaccharid.  In  the  alimentary  canal  it  is  split  up 
by  the  action  of  acids,  ferments,  and  bacteria  (see  the  impor- 
tant action  of  germs  here)  into  grape-sugar  and  fruit-sugar. 
If  eaten  in  large  quantities,  some  of  it  must  pass  into  the  blood 
unconverted  into  glucose  or  fruit-sugar  (levulose).  Fruit- 
sugar  and  milk-sugar  enter  the  blood  unchanged.  Here  is  a 
practical  point :  diabetics  may  eat  them  sparingly,  and  the 
same  applies  to  saccharin.  Cellulose  from  wood-pulp,  of 
which  cotton  is  a  typical  example,  is  isomeric  with  starch. 
If  eaten  it  is  never  absorbed.  In  the  intestinal  canal  it  is 
fermented  and  changed  by  bacteria  into  methane,  carbonic 
acid,  acetic  acid,  and  butyric  acid.  From  the  intestinal  wall 
the  carbohydrate  stream  flows  through  the  portal  vein  to  the 
liver.  Various  forms  of  carbohydrates  are  in  this  stream, 
according  to  the  food  taken.  There  may  be  glucose,  levulose, 
lactose,  saccharose,  milk-sugar,  with  some  dextrin  and  mal- 
tose. Whatever  the  form  of  the  carbohydrate,  the  liver  at 
once  takes  hold  of  it  and  converts  it  into  glycogen,  which  is 
deposited  in  flakes  in  the  hepatic  cells,  and  probably  in  loose 
combination  with  albumin.  The  liver  closely  guards  the 
amount  of  the  sugar  in  its  blood  leaving  it.  The  sugar  in 
the  blood  is  grape-sugar.  There  may  be  a  very  little  glyco- 
gen. The  liver  always  keeps  a  certain  percentage  of  grape- 
sugar  in  the  blood.  It  excretes  a  little  glycogen,  but  first 
converts  it  into  grape-sugar,  and  in  health  the  percentage  is 
always  about  the  same.  There  is  some  glycogen  in  the 
muscles.  The  muscles  get  their  glycogen  from  their  own 
store  of  grape-sugar.  The  liver  collects  the  carbohydrates 
from  the  blood  of  the  portal  vein,  fixes  them  as  grape-sugar, 
and  gives  them  up  to  the  general  blood  when  needed.  Gly- 
cosren  is  formed  from  albumin  as  well  as  from  carbohydrates. 
This  is  of  practical  importance,  and  tells  us  why  diabetics 
sometimes  consume  their  own  tissues  to  support  life. 

29  449 


FORTY   YEARS   IN   THE   MEDICAL   PROFESSION 

The  carbohydrates  are  always  present,  coming  from  the 
carbohydrates  and  proteids  of  the  food.  The  muscle-cells  are 
always  consuming  them,  and  furnish  force  and  heat  from 
their  combustion.  So  long  as  grape-sugar  is  in  the  blood  in 
physiological  quantity,  none  goes  out  with  the  urine.  When 
a  muscle  is  worked,  it  consumes  sugar  by  oxidation.  A 
muscle  can  work  by  consuming  albumin,  but  not  long.  It 
will  then  seize  fat  as  most  available.  For  the  muscle  to  use 
it,  the  liver  converts  it  into  sugar.  The  liver  only  does  this 
when  there  are  no  carbohydrates  or  albumin  for  it  to  use  for 
the  purpose.  Now  we  see  why  the  diabetic  so  often  loses  his 
fat  rapidly:  the  liver  takes  it  to  make  sugar  for  fuel  when 
the  normal  formation  of  fuel  sugar  is  running  off  by  the  kid- 
neys, possibly. 

What  happens  if  the  carbohydrates  are  in  excessive  supply 
in  the  system?  Three  hundred  grammes  of  glycogen  is  the 
normal  amount  in  the  system.  When  this  has  been  made  by 
the  carbohydrates,  any  excess  of  carbohydrates  is  deposited 
as  fat.  If  there  be  still  too  much  carbohydrates,  the  indi- 
vidual gets  hyperglycsemia, — too  much  sugar  in  the  blood. 
If  the  percentage  of  sugar  in  the  red  blood  exceeds  0.2,  ali- 
mentary glycosuria  results,  which  is  not  diabetes  mellitus. 
If  a  man  eat  1 50  to  200  grammes  of  cane-sugar,  he  will  prob- 
ably, in  an  hour,  have  alimentary  glycosuria,  which  will  last 
for  three  hours.  The  same  thing  will  happen  if  he  eat  120 
grammes  of  milk-sugar,  250  grammes  of  glucose,  or  200 
grammes  of  levulose,  or  fruit-sugar. 

A  healthy  man  does  not  have  diabetes,  because  his  glyco- 
gen reservoirs  can  hold  all  of  his  sugar.  In  the  diabetic  prob- 
ably these  reservoirs  overflow  and  flood  the  blood  with  sugar. 
A  temporary  glycosuria  may  be  caused  by  hepatic  disturb- 
ances, muscular  disturbances,  nerve  disturbances,  apoplexy, 
poisonings,  passage  of  gall-stones,  exophthalmic  goitre,  and 
some  other  conditions.  The  liver,  the  muscles,  and  the  glands 
all  store  up  glycogen.  We  may  eat  an  excess  of  carbohy- 
■drates,  and  at  the  same  time  be  suffering  from  a  diseased 
liver  of  the  most  consuming  nature,  yet  not  have  even  a  tem- 

450 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

porary  glycosuria.  Therefore,  we  may  reason,  the  cause  of 
diabetes  melHtus  does  not  reside  in  the  liver. 

There  is  a  temporary  diabetes  caused  by  ];hloridzin  poison- 
ing. Phloridzin  is  a  glucoside  from  the  roots  of  the  apple 
and  cherry.  It  acts  on  the  renal  epithelium  to  cause  it  to  lose 
its  power  of  holding  back  the  sugar  when  filtering  out  the 
urine.  It  is  a  toxic  glycosuria,  in  which  unfler-consumption 
is  joined  to  over-production.  This  fact  seems  to  impress  von 
Noorden  with  the  fact  that  possibly,  after  all,  the  kidneys 
themselves  may  be  a  pathological  factor  in  diabetes  mellitus. 
Extirpate  the  pancreas  of  a  dog,  and  so  long  as  he  lives  he  is  a 
diabetic.  Lepine  says  the  pancreas  produces  a  ferment  which 
enters  the  circulation  and  causes  a  breaking  up  of  the  grape- 
sugar  molecules  within  the  blood.  This  is  a  pretty  theory, 
and  may  be  a  true  one  to  explain  cases  of  pancreatic  diabetes. 

Does  the  over-production  of  glucose  in  the  system  cause 
diabetes?  Von  Noorden  does  not  think  so.  He  does  not 
think  there  is  an  incapacity  of  storage  for  the  glycogen,  thus 
letting  out  the  sugar  into  the  blood.  Glycogen  is  really  ani- 
mal starch,  and  resembles  inulin.  Is  insufficient  consumption 
of  the  sugar  in  the  tissues  a  cause?  If  the  insufficient  con- 
sumption of  the  sugar  in  the  cells  were  a  factor,  this  sugar 
could  still  be  converted  into  fat  and  stop  the  diabetes,  but  it 
is  not,  for,  as  a  rule,  diabetics  lose  their  fat.  Von  Noorden 
rather  assumes  as  factors  parts  of  several  theories,  chiefly 
insufficiency  of  glycogen  reservoirs  and  insufficient  sugar  con- 
sumption. The  latter  may  include  inadequate  distribution 
of  carbohydrates,  diminution  of  the  property  residing  in  the 
tissues  of  seizing  and  breaking  up  the  sugar  molecule,  diminu- 
tion of  the  property  residing  in  the  tissues  of  compressing 
the  sugar  molecule  into  a  fat  molecule.  Glycosuria  resulting 
from  an  over-production  of  sugar  from  albumin  and  fat  is 
not  known  to  occur,  he  says.  Over-production  plays  no  part 
in  diabetes  mellitus  in  man,  says  von  Noorden,  but  diabetes 
due  to  diminished  consumption  of  carbohydrates  is  an  estab- 
lished fact.  It  is  immaterial  what  may  be  regarded  as  the 
causative  factor  of  this  diminished  consumption,   it  stands 

451 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

in  the  foreground  in  experimental  pancreatic  diabetes,  and 
probably  also  in  the  great  majority  of  cases  of  diabetes  mel- 
litus  in  man. 

These  are  the  views  of  probably  our  foremost  thinker  on 
the  subject,  and,  although  an  improvement  on  those  of  men 
before  him,  still  lack  the  precision  and  requirements  of  abso- 
lute scientific  truth  founded  on  absolute  scientific  fact.  All 
we  can  do  at  present  is  to  adhere  to  the  theories  advanced, 
and  undoubtedly  most  cases  of  diabetes  mellitus  can  be  ex- 
plained quite  satisfactorily  in  one  of  these  ways.  In  the 
dietetic  form  more  sugar  is  taken  into  the  economy  than  the 
liver  can  work  up.  In  the  nervous  forms  there  is  a  vasomotor 
disturbance  which  interferes  with  the  blood-supply  of  the 
liver,  and  also  with  its  glycogenic  functions.  In  the  pan- 
creatic forms  the  pancreas  may  fail  to  secrete  its  sugar-de- 
stroying ferment,  and  thus  the  blood  may  become  surcharged 
with  glucose.  The  fluid  of  the  pancreas  contains  at  least 
three  enzymic  bodies  which  play  important  parts  in  diges- 
tion. One  of  these  is  diastatic,  is  capable  of  converting  starch 
into  sugar,  and  is  supposed  to  be  identical  with  the  ptyalin  of 
the  saliva.  One  gramme  of  the  pancreatic  juice  of  a  dog 
containing  only  .014  gramme  of  organic  solids  will  convert 
4.672  grammes  of  starch  into  sugar  in  a  half-hour.  Impair- 
ment of  this  function  surely  must  have  a  great  effect  on  the 
sugar  of  the  economy. 

Now  we  come  to  another  theory  as  to  the  origin  of  dia- 
betes mellitus  in  man,  and  although  it  is  a  startling  one,  it 
is  by  no  means  an  erratic  one.  Dr.  Abraham  Mayer,  of  New 
York,  advances  the  theory  that  it  is  the  result  of  the  perni- 
cious influence  of  a  specific  bacterium  or  its  ptomaine  in  the 
organism,  acting  centrally  on  certain  brain-centres,  or  periph- 
erally on  the  glycogenic  reservoirs.  The  nervous  system  con- 
trols the  normal  production  of  sugar  in  the  body.  If  from 
accident,  neoplasm,  worry  or  mental  strain,  poisons,  etc.,  this 
influence  is  impaired  or  abolished,  the  bacteria  and  their  pto- 
maines exert  their  influence  for  harm.     The  bacteria  invade 

452 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

the  organism  ;  in  health  the  normal  resistance  of  the  economy 
hokis  them  in  check,  or  perhaps  some  ferment  physiokjgically 
produced  by  metaboHc  changes  in  certain  organs  acts  as  an 
antitoxin  to  them.  Granting  this,  we  will  cure  the  diabetes 
produced  by  the  bacteria  by  exhibiting  a  bactericide.  Dr. 
Mayer  reports  bichloride  of  mercury  as  the  remedy  to  do 
this.  His  treatment  is  as  follows :  A  history  of  the  case  is 
obtained,  and  the  patient  is  weighed.  The  quantity  of  urine 
passed  in  twenty-four  hours  is  noted,  the  specific  gravity  is 
taken,  the  quantity  of  sugar  is  estimated,  and  other  abnormal 
characteristics  are  noted.  If  the  urine  fails  to  react  to  Ger- 
hardt's  test,  the  patient  is  put  on  an  antidiabetic  diet  for 
two  weeks,  during  which  time  bichloride  is  taken,  beginning 
with  one-twelfth  of  a  grain  three  times  a  day,  and  in  three 
days  increase  to  one-tenth  of  a  grain.  In  a  w'eek's  time  one- 
sixth  of  a  grain  is  given  after  each  meal,  well  diluted  with 
water.  It  acts  at  first  on  the  bowels  and  does  not  salivate. 
In  three  weeks  the  sugar  has  been  greatly  reduced,  and  the 
patient  has  improved  in  every  way.  Now  the  dose  of  bichlo- 
ride is  reduced  to  one-sixteenth  of  a  grain  three  times  a  day. 
The  diet  is  now^  increased  a  little,  or  rather  is  not  so  severely 
restricted.  The  urine  is  examined  every  day,  and  the  even- 
ing urine  tested.  From  time  to  time  the  drug  is  suspended, 
but,  even  if  the  sugar  entirely  disappears,  the  bichloride  is 
given  in  small  doses. 

These  cases  he  treated  were  not  syphilitic  cases.  Cases 
with  a  history  of  lues  (congenital  syphilis,  probably  meant) 
showed  marked  improvement.  Dr.  ]\Iayer  claims  the  drug 
as  a  specific  in  diabetes,  and  recommends  its  general  trial  by 
the  profession.  Dr.  G.  W.  McCaskey  also  says  it  will  be  well 
to  investigate  closely  the  bacteria  of  the  stomach  and  intes- 
tines in  cases  of  diabetes  mellitus,  not  wath  the  expectation 
of  supplanting  dietetic  treatment,  but  with  the  view  of  aiding 
with  suitable  treatment  for  possibly  existing  virulent  bacte- 
rial protozoa  or  parasitic  growths.  These  in  some  way  may 
afifect  the  ferments,  checking  or  increasing  the  normal  sugar 

453 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

supply  of  the  system,  thus  acting,  whether  it  be  in  over-supply 
or  under-supply. 

Von  Noorden  gives  some  interesting  points  in  regard  to 
obesity  and  diabetes  and  the  form  called  by  some  lipogenous 
diabetes.     In  all  cases  of  diabetes  the  oxidation  of  carbohy- 
drates is  restricted.     Glycosuria  and  hyperglycccmia  can  only 
follow  when  the  fat-forming  as  well  as  the  oxidizing  cells 
have  lost  their  power  of  arresting  the  sugar  molecule.     He 
thinks  it  is  possible  that  both  consumption  (oxidation)  and 
storage  (fat  conversion)  of  the  materials  are  interfered  with 
by  a  common  cause,  as,  for  example,  the  resistance  of  the 
diabetic  tissue  to  glycogen  formation.     You  may  conceive  a 
case  in  which  the  ability  to  burn  up  sugar  in  the  organism  is 
alone  interfered  with,  whilst  the  carbohydrate  conversion  to 
fat  continues.     Here  the  cells  are  bathed  in  a  rich  sugar  so- 
lution, yet  they  starve,  because  they  cannot  seize  the  sugar 
molecule.     Hence  follows  a  tissue  hunger,  which  by  reflex 
action  starts  a  sharper  appetite,  and  hence  more  food  is  taken, 
and  from  this  more  fat  is  deposited.     This  person  is  really 
diabetic,  yet  he  does  not  excrete  sugar  externally,  but  in  the 
fatty  tissues,  and  in  the  end  almost  always  becomes  a  true 
diabetic.    Here  is  a  relationship  between  obesity  and  diabetes, 
and  there  may  be  some  such  relationship  between  gout  and 
diabetes.     Some  cases  are  at  first  gouty  and  then  become 
diabetic,  and  there  are  cases  the  reverse.    Then  there  are  cases 
in  which  the  two  diseases  coexist.    The  diabetes  coming  first 
gives  the  worst  prognosis.    The  cases  in  which  there  is  coex- 
istence are  usually  not  severe  cases.     I  have  seen  such  cases 
in  men  of  middle  age  who  violated  every  hygienic  law  appli- 
cable to  their  condition,  and  yet  they  did  well  and  appeared 
to  prosper,  until  suddenly  they  yielded  to  some  intercurrent 
attack,  like  apoplexy  or  diabetic  coma,  to  which  their  condi- 
tion rendered  them  continually  liable. 

Von  Noorden  appears  to  think  diabetes  mellitus  is  not  com- 
mon among  the  insane.  My  own  experience  leads  me  to  be- 
lieve there  is  quite  a  percentage  of  the  insane  diabetic,  and 
alimentary  diabetes  is  quite  common  if  they  are  not  well  regu- 

454 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

lated  as  to  their  diet,  but  allowed  to  give  way  to  their  animal 
instincts.  There  are  no  chronic  medical  cases  which  1  ap- 
proach with  more  sense  of  responsibility  than  T  do  those  of 
diabetes  mcllitiis.  No  man  has  any  right  to  take  them  unless 
he  has  made  himself  familiar  with  the  subject,  and  it  is  not 
right  to  dismiss  them  with  a  placebo  and  tell  them  to  live  on 
nitrogenous  diet.  Every  case  requires  profound  and  deep 
study,  and  demands  ever-watchful  and  anxious  care.  In  very 
many  cases  life  may  be  prolonged  indefinitely  under  proper 
surveillance,  without  which  the  end  may  come,  and  in  many 
cases  does  come,  prematurely.  Remember,  one  cannot  live  on 
nitrogenous  foods  indefinitely.  Such  foods  are  of  easy  diges- 
tion, and  are  not  prone  to  putrefaction,  but  they  are  deficient 
in  nucleo-albumin,  which  is  essential  to  the  building  up  of  the 
red  blood-corpuscles  and  for  supplying  energy  to  the  nervous 
system.  Living  a  long  time  on  such  diet  produces  anaemia 
and  debility,  whether  the  person  be  healthy  or  diabetic. 

Let  us  look  at  gluten,  so  much  spoken  of  as  diet  for  the 
diabetic.  It  is  the  nitrogenous  element  of  the  food  cereals. 
It  has  been  said  that  gluten  and  water  constitute  all  that  is 
necessary  for  food  and  drink.  Gluten  really  is  not  a  single 
food  element.  There  are  four  substances  in  it, — vegetable 
albumin,  vegetable  casein,  vegetable  fibrin,  and  vegetable  gel- 
atin, the  latter  being  considered  an  albumin-saving  food,  and 
there  is  a  possibility  of  forming  fat  from  the  albuminates. 
If  we  could  get  a  pure  gluten  food,  and  add  fat  to  it  by  butter 
and  milk  and  such  methods,  we  could  get  a  more  desirable 
food  for  those  unable  to  use  the  carbohydrates.  Diabetic  pa- 
tients are  often  difficult  to  manage.  Early  in  the  case  get 
yourself  en  rapport  with  him,  get  his  confidence,  and  have 
him  consult  you  as  frequently  as  possible. 

Diabetes  is  doubtless  increasing  in  frequency  in  this  coun- 
try. Wear  and  tear  is  greater  every  day,  over-consumption 
of  the  carbohydrates  is  increasing,  and  the  nature  of  our  foods 
is  causing  us  to  be  more  and  more  the  subjects  of  unfavorable 
bacterial  action.  Americans  are  among  the  great  carbohy- 
drate consumers  of  the  world.     It  is  not  necessary  to  say 

455 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

much  of  the  diagnosis,  which  is  not  difficuh  usuah}'.  Keep 
your  eyes  open,  for  there  are  doubtless  intermittent  forms. 
Tuberculosis  of  some  form  may  mask  it,  and  a  word  or  an 
action  may  give  us  a  hint.  The  first  hint  may  come  from 
the  eye,  from  a  tendency  to  stupor  or  coma,  from  a  sexual 
neurosis,  from  a  vaginal  pruritis  in  the  female,  from  a  neu- 
ritis of  the  arrn  or  lower  extremity,  especially  a  sciatica, 
the  diminution  of  the  tendon  reflexes,  a  loss  of  flesh,  ex- 
haustion, spongy  gums,  dry  skin,  great  thirst  or  strong 
appetite,  constipation  of  the  bowels,  polyuria,  a  sticky  drop 
of  urine,  possibly  on  the  shoe,  whitish  in  color  after  evapo- 
ration, glucose  in  the  urine  by  test.  As  to  the  tests  for 
sugar,  the  fermentation  test  with  yeast  is  a  sure  one,  and 
one  b}'-  which  we  can  tell  the  comparative  amount  of  sugar 
in  the  urine.  I  like  Moore's  test  as  an  easy  one.  There  must 
be  five  per  cent,  of  sugar  present  to  make  it  available.  If  you 
see  the  specific  gravity  over  1025,  look  out  for  sugar.  Tyson 
has  seen  sugar  as  low  as  loio.  The  low  proportion  of  other 
ingredients  caused  this,  perhaps,  or  fermentation.  Do  not 
examine  your  specimens  after  fermentation  and  the  sugar  has 
gone  off.  Fehling's  solution  affords  a  good  test,  and  by  it 
you  can  calculate  the  quantity  of  sugar  present.  It  may  be 
purchased  in  tablet  form,  and  is  handy.  It  does  not  keep  long 
made  up,  nor  does  Pavy's.  Trommer's  test  is  a  fair  test,  and 
will  show  under  favorable  conditions  as  low  as  one  per  cent, 
of  sugar.  You  must  get  an  orange-red.  After  it  cools,  and 
the  precipitate  is  only  light  yellow,  you  may  only  have  re- 
duced uric  acid,  creatinin,  etc.,  and  thus  make  a  grave  mis- 
take. Nylander's  test  is  von  Noorden's  favorite :  Take  four 
grammes  of  sodium  tartrate  and  dissolve  it  in  one  hundred 
cubic  centimetres  of  a  ten  per  cent,  solution  of  caustic  soda, 
to  which  two  grammes  of  bismuth  subnitrate  have  been  added. 
Heat  this  to  122°  F.  Cool  and  filter.  Boil  ten  cubic  centi- 
metres of  urine  in  one  cubic  centimetre  of  the  solution  two 
minutes.  If  sugar  is  present,  metallic  bismuth  is  thrown 
down.  This  is  black,  and  the  fluid  is  dark  or  even  black.  If 
there  is  no  black,  there  is  no  sugar.    This  test  will  show  sugar 

456 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

if  it  exists  only  to  tlic  amount  f)f  one  per  cent.  It  is  neces- 
sary often  to  test  for  acetone,  aceto-acetic  acifl,  beta-oxybu- 
tyric  acid,  or  oxyl)Utyric  acid.  The  latter  is  important,  for 
when  present,  diabetic  coma  ]irobal)ly  soon  will  follow.  For 
tests  for  these  the  reader  is  referred  to  text-books. 

The  pathological  and  bacteriological  laboratories  which 
are,  or  should  be,  established  in  every  community,  in  which 
such  investigation  can  be  made,  are  a  great  advantage  and 
help  to  practitioners  of  medicine,  and  of  untold  benefit  to 
sufferers  from  disease.  If  your  patient  be  pregnant,  there 
may  be  more  thorough  investigation  needed.  Before  preg- 
nancy, menstruation  is  usually  very  much  diminished.  In 
about  two-thirds  of  the  cases  pregnancy  goes  on  to  the  end. 
In  about  one-third  of  the  cases  miscarriage  takes  place  late 
in  the  pregnancy.  For  her  ov^ai  sake  and  the  baby's  sake 
the  diabetic  mother  should  not  nurse  her  child. 

Pruritus  vulvae  is  very  common  in  the  pregnant  woman, 
and  so  are  boils  and  carbuncles,  and  much  sugar  goes  off  by 
the  urine.  Some  one  has  said  diabetic  women  are  more  apt 
to  produce  female  children,  because  for  the  perfect  ripening 
of  the  ovum  oxidation  must  be  perfect;  that  is  to  say,  no 
sugar  must  be  left  unburnt.  When  any  is  left,  the  ovum  be- 
comes less  ripe  and  less  well  nourished ;  hence  the  properties 
of  its  protoplasm  are  less  well  developed,  and  by  the  theory  of 
crossed  inheritance  it  is  more  than  likely  to  produce  a  female 
child.  When  you  commence  with  your  patient  you  want  his 
family  history  and  his  own  history  from  the  time  he  noticed 
illness.  Record  his  weight  and  note  it  from  time  to  time. 
This  is  of  great  importance,  as  may  be  well  seen.  Now  you 
want  to  find  out  his  condition  as  to  sugar.  Put  him  on  his 
usual  diet  for  several  days,  and  measure  and  take  account  of 
the  glucose  in  the  urine.  For  the  same  length  of  time  let  the 
patient  take  an  absolute  diet,  say  of  rare  beef  and  tea  with- 
out cream  or  sugar,  and  then  take  an  account  of  the 
sugar,  and  you  will  see  where  you  are.  From  this  you 
will  learn  much.  vSome  people  bear  carbohydrates  well,  and 
some  do  not;   so  take  this  into  account  with  a  new  patient, 

457 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

and  go  on  and  study  his  tolerance  for  carbohydrates.  You 
can  soon  fix  his  hmit  with  careful  watching.  Remember,  the 
diabetic  probably  does  not  burn  sufficient  of  his  carbohydrates 
for  fuel  and  strength,  he  may  not  store  sufficient  as  glycogen, 
and  he  may  not  convert  sufficient  into  fat.  One  day  he  may 
do  worse  in  these  physiological  duties  than  he  may  the  next 
day.  Now,  suppose  he  only  eats  the  rare  beef  and  drinks  the 
tea,  and  you  find  considerable  sugar,  what  then?  It  argues 
badly.  He  must  be  making  the  sugar  from  his  albumin  and 
letting  it  gradually  into  the  circulation,  and  not  even  con- 
•suming  this.  His  glycogen  storage  must  be  seriously  dis- 
abled. The  splitting  up  of  the  sugar  molecule  in  the  tissues 
and  its  compression  into  fat  must  be  seriously  disturbed. 
Here  the  beef  is  possibly  a  dangerous  diet,  for  the  patient 
will  get  too  much  sugar  even  from  it.  Yet  if  we  do  not  give 
it,  will  he  not  use  too  much  of  his  own  albuminous  tissues  to 
produce  it  ?  Your  patient  is  in  great  danger  here.  It  is  your 
duty  to  watch  him  and  test  him  on  different  diets  until  you 
get  what  suits  him  best. 

In  testing  the  urine  in  these  cases,  indeed  in  all  cases,  it 
is  best  to  take  specimens  from  both  the  morning  and  evening 
voidings.  If  we  can  get  a  carbohydrate  to  go  through  the 
kidneys  unchanged  and  yet  give  heat  and  force  for  the  system, 
we  will  secure  a  great  gain.  Alcohol  within  bounds  is  a  great 
help  in  treatment.  Spirit  is  its  best  form,  and  California  un- 
colored  pure  brandy  is  the  best  spirit.  Next  to  this  comes 
Scotch  whiskey.  American  whiskeys  and  French  brandies 
have  more  sugar  from  their  caramel  coloring.  Claret  is  the 
best  wine,  and  the  Rhine  wines  come  next.  Champagne, 
unless  absolutely  dry,  is  a  poison,  and  so  are  the  sparkling 
Moselles.  The  European  physicians  allow  now  and  then  a 
glass  of  dry  sherry.  To  my  mind  sherry,  Madeira,  and  port 
should  never  be  offered  a  diabetic.  Gin  is  too  stimulating 
to  the  kidneys.  Malt  liquors  of  all  kinds  must  be  absolutely 
shunned.  Much  comfort  can  be  gotten  from  the  effervescing 
waters.  A  glass  of  carbonic  acid  water  with  a  thimbleful 
of  brandy  is  as  palatable  as  champagne. 

458 


FORTY    YEARS    IN    THE    MEI^ICAL    PROFESSION 

If  your  patient  has  a  voracious  appetite,  take  this  into  con- 
sideration when  testing  for  sugar.  If  the  stools  are  large, 
you  may  expect  tlic  pancreas  to  be  involved.  If  your  patient 
becomes  ill  from  other  causes,  of  course  the  sugar  is  flimin- 
ished,  because  there  is  less  formed.  This  may  even  happen 
in  advanced  cases  when  tuberculosis  coexists.  Von  Noorden 
suggests  that  in  bacterial  diseases  they  may  give  a  ferment, 
and  cause  the  cells  then  to  dispose  of  more  sugar,  and  thus 
get  rid  of  it  in  that  way.  A  friend  at  my  elbow  suggests,  if 
they  can  dispose  of  it  thus  easily,  why  cannot  they  play  some 
important  part  in  its  formation  ? 

I  have  seen  two  cases  of  diabetes  mellitus  in  persons  above 
middle  age  get  well.  One  was  a  colored  preacher,  of  good 
character  and  habits,  and  the  other  was  a  married  white 
woman.  The  man  was  of  large  frame  and  muscular,  and 
not  inclined  to  obesity.  The  woman  was  short  and  stout  and 
quite  fat,  the  mother  of  a  large  family,  and  in  good  circum- 
stances. I  have  seen  both  cases  recently,  and  neither  shows 
sugar  in  the  urine,  and  both  are  fairly  well,  except  the  in- 
firmities of  age,  both  being  nearly  eighty  years  old.  Some 
years  ago  I  saw  the  man  a  few  times,  and  gave  him  what  I 
considered  good  advice.  He  then  disappeared.  In  a  year  I 
saw  him  again,  and  he  still  had  a  large  amount  of  sugar  in 
his  urine.  I  asked  him  what  he  had  been  doing  for  himself. 
He  said  he  had  taken  some  of  the  medicine  (ten  drops  of  the 
fluid  extract  of  jambul  seeds)  for  a  time,  and  then  stopped 
and  lived  on  the  best  diet  he  could  get.  Two  or  three  years 
after  this  my  attention  was  again  called  to  this  man.  He 
looked  very  well,  and  like  anything  but  a  diabetic.  I  procured 
a  specimen  of  his  urine,  and  found  it  normal  in  every  way. 
He  said  he  felt  well,  had  been  pursuing  his  calling  and  work- 
ing at  odd  jobs,  and  had  eaten  everything  that  came  to  hand. 
The  woman  I  kept  under  constant  surveillance.  In  about 
two  years,  under  the  usual  treatment  applicable  to  such  a 
case  and  the  exhibition  of  jambul,  I  found  the  sugar  to  dis- 
appear. For  several  years  she  has  had  no  sugar,  but  has  now 
and  again  attacks  of  eczema  or  pruritus. 

459 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

I  am  well  aware  that  some  cases  of  diabetes  stop  when  the 
patient  becomes  gouty  and  granular  atrophy  of  the  kidneys 
supervenes,  and  this  is  a  most  interesting  condition  and  one 
causing  us  to  think  of  many  possibilities  as  to  its  pathological 
factors.  The  cases  I  have  quoted  were  not  such  cases  :  neither 
had  had  gout  in  the  form  of  arthritis,  and  neither  had  inter- 
stitial nephritis. 

Dr.  H.  D.  Beyea  has  reported  an  interesting  case,  where 
he  removed  an  ovarian  cyst  from  a  diabetic,  followed  by  re- 
covery, wonderful  to  relate,  and,  more  wonderful  still,  the 
diabetic  symptoms  all  disappeared.  This  case  is  one  worthy 
of  close  watching  and  close  study  in  all  of  its  phases. 

A  healthy  person,  for  each  two  and  one-fifth  pounds  of 
weight,  consumes  at  rest  30  to  35  calories;  in  motion,  30  to 
40  calories ;  at  moderate  work,  40  to  50  calories.  A  calorie, 
remember,  is  the  amount  of  heat  required  to  raise  one  kilo- 
gram of  water  i  °  C. 

Von  Noorden  takes  a  diabetic  woman  doing  light  work. 
When  well,  she  needed  1925  calories  per  day;  diabetic,  she 
lost  210  calories;  therefore  she  consumed  210  calories  of  her 
own  tissue.  By  calculation  she  lost  38.9  calories  through 
albumin,  and  therefore,  by  the  consumption  of  some  of  her 
nitrogenous  substance,  she  lost  171.  i  calories.  Fat  was  the 
only  substance  available,  and  this  took  18.4  grammes  of  fat, 
each  gramme  yielding  9.3  calories,  making  18.4  X  9-3  = 
1 7 1. 1 2  calories  lost  by  fat;  therefore  she  must  eat  albu- 
minates and  fats  in  excess  to  keep  up  with  a  person  in  good 
health.  If  she  eats  carbohydrates,  they  run  ofif  as  sugar  by 
the  urine,  and  furnish  no  fuel  for  steam  or  power.  They 
only  check  hunger  for  a  little  while,  and  tissue  hunger 
scarcely  at  all.  The  point  to  watch  is  when  she  can  begin 
to  tolerate  some  carbohydrates,  for  albuminates  and  fats  will 
not  do  all  the  time ;  she  will  either  become  weak  and  anaemic 
on  them  or  nervous  from  loss  of  nerve-power,  or  will  consume 
her  own  tissues  to  get  some,  at  least,  from  them.  Here  is  a 
perfect  illustration  of  how  to  watch  a  diabetic  and  what  we 
are  to  watch  for,  and  what  we  may  expect  under  certain  con- 

460 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

ditions,  even  up  to  diabetic  coma.  Diabetics  excrete  much 
nitrogen  because  they  eat  much.  If  there  is  more  in  the 
urine  than  goes  in  by  the  food,  lliere  is  a  consumption  of  the 
nitrogenous  tissues  going  on,  and  we  must  seek  to  check  it. 
The  more  nitrogen  wasted  in  this  way,  the  worse  the  glyco- 
suria, and  we  must  check  the  exhibition  of  carbohydrates. 
A  toxaemia  may  arise  to  affect  the  protoplasm,  and  coma  may 
come.  Von  Noorden  gives  the  nitrogenous  substances  in 
diabetic  urine  as  urea,  ammonia,  creatinin,  uric  acid,  and 
albumin.  The  non-nitrogenous  substances  as  acetone,  aceto- 
acetic  acid,  and  beta-oxybutyric  acid.  Their  common  source 
is  albumin,  body  albumin,  not  albumin  of  the  food. 

Diabetic  coma  is  an  acid  intoxication  of  some  kind.  Some 
think  it  due  to  oxybutyric  acid,  and  some  to  acetone  and 
aceto-acetic  acid.  Von  Noorden  does  not  think  the  latter  the 
cause.  He  thinks  diabetic  coma  comes  from  a  paralyzing  of 
the  brain  and  a  destruction  of  protoplasm  by  a  toxaemia. 
To  me  it  appears  the  great  loss  of  the  salts  of  potash,  soda, 
etc.,  by  the  urine  may  be  a  cause,  the  absence  of  these  ren- 
dering more  or  less  inert  the  protoplasm  of  the  organic  cell. 
Oxybutyric  acid  in  the  blood  is  a  sign  of  its  coming.  I  have 
never  seen  pneumaturia  or  gas  in  the  bladder  in  diabetes,  yet 
such  cases  are  reported.  Germs  are  probably  introduced  from 
without,  as  by  catheterization,  and  cause  it.  The  skin  is 
usually  very  dry  and  harsh,  and  germs  are  very  active  in 
the  diabetic;  hence  the  slightest  surgical  operation  is  at- 
tended with  danger.  The  books  give  the  operation  for  phy- 
mosis  as  a  very  dangerous  one,  probably  from  some  local  in- 
fection through  the  urine.  Granulations  of  wounds  are  apt 
to  slough,  and  fractures  may  be  attended  by  extreme  debility 
and  danger,  if  of  the  larger  bones,  bed-sores  being  a  very 
serious  feature  if  the  patient  is  compelled  to  rest  in  bed.  In- 
deed, any  accident  or  intercurrent  illness  is  a  cause  of  the 
most  serious  anxiety  in  diabetics,  and  sometimes  unlooked-for 
deaths  are  to  be  solved  by  looking  for  the  evidences  of  sugar 
in  the  economy,  which  had  not  been  suspected  by  the  indi- 
vidual or  possibly  by  his  doctor. 

461 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

.  Under  thirty  years  of  age  most  diabetics  die  of  tubercu- 
losis within  a  reasonably  short  time,  and  the  younger  the 
patient  the  more  rapid  the  disease,  as  a  rule.  I  have  never 
recognized  it  under  twelve  years  of  age.  The  better  the  cir- 
cumstances of  the  patient,  the  better  are  his  chances.  This 
holds  good  for  two  reasons.  Every  advantage  that  wealth 
can  give  is  a  help,  and  these  people,  as  a  rule,  have  the  ad- 
vantages of  education,  and  can  conduct  their  case  on  their 
own  part  more  intelligently.  It  is  difficult  to  restrain  in  diet 
or  otherwise  a  rough,  ignorant,  uncouth  man,  a  silly  woman, 
or  an  irresponsible  child. 

Von  Noorden  says  tubercle  bacilli  are  difficult  to  find  at 
times  in  the  sputa  of  diabetics  with  consumption,  and  that 
arteriosclerosis  is  common  in  some  degree  or  another.  Some 
hypertrophy  of  the  heart  is  often  a  help,  and  a  weak  heart  is 
serious.  Always  look  to  the  heart  of  your  patient,  and 
measure  his  strength  by  that  and  other  ways,  and  look  to 
the  condition  of  the  arteries,  etc.  Albuminuria  is  not  a  very 
serious  sign,  as  a  rule.  If  caused  by  gouty  kidney,  the  sugar 
may  check  or  disappear.  A  graver  cause  may  be  arteritis. 
Differentiate  by  the  microscope,  observing  tube  casts,  etc. 
Von  Noorden  says  glycogen  clods  are  found  in  the  kidneys 
after  death.  Remember,  the  lymphatic  glands  often  swell  in 
diabetics;  the  cause  is  possibly  often  tuberculosis.  Death 
from  uraemia  may  come  in  the  kidney  cases,  so  be  careful  to 
differentiate  such  from  coma  cases.  Coma  may  come  sud- 
denly or  be  preceded  for  a  longer  or  shorter  time  by  severe 
headache,  and  the  symptoms  may  even  simulate  intoxication 
from  alcohol  or  opium,  or  any  other  intoxicant.  After  some 
hours  coma  comes  on.  The  pupils  are  dilated,  the  breath  is 
one  long  and  one  short,  cyanosis  increases,  the  odor  of  acetone 
is  on  the  breath,  an  apple  or  hay  odor  probably  (convulsions 
are  rare).  The  urine  reacts  with  chloride  of  iron,  and  sugar 
may  be  present  or  absent.  Recovery  is  seldom,  and  in  two  or 
three  days  the  patient  sleeps  away. 

Remedies  are  of  little  avail.     Alkalies  are  recommended 
on  general  principles.     The  best  reason  for  giving  alkalies 

462 


FORTY    YEARS    IN    THE   MEDICAL    PROFESSION 

is  the  fcivoral)le  action  they  have  on  tiic  protoi>lasm  oi  the 
organic  cells.  A  man  cannot  live  on  distilled  water  as  a 
constant  drink.  Intravenous  injection  of  the  normal  salt 
solution  is  recommended.  Tyson  has  seen  good  results  from 
injecting  it  into  the  tissues.  I  should  use  it  very  freely 
by  the  rectum.  Diabetics  bear  the  slightest  operations  so 
badly,  I  w^ould  even  be  afraid  of  intravenous  or  tissue  injec- 
tions. If  the  patient  should  get  well,  sloughing  would  almost 
surely  follow  the  latter,  and  sudden  death  might  come  with 
the  former.  As  a  rule,  you  will  not  find  coma  coming  on 
whilst  the  patient  holds  his  fat.  If  there  are  any  symptoms 
of  coma,  a  safe  rule  is  to  change  the  diet,  whatever  it  may  be. 
The  cause  of  diabetes,  whatever  it  is,  causes  rapid  oxidation 
of  the  tissues,  and  whilst  the  fat  remains  it  probably  exhausts 
its  force  in  oxidizing  it. 

As  I  have  no  prearranged  plan  in  waiting  this  article,  but 
take  matter  just  as  it  comes,  let  us  take  up  thyroid  treatment 
in  diabetes  mellitus,  as  we  have  spoken  of  fat.  The  office  of 
the  thyroid  in  the  system  is  probably  a  secretory  one.  It  fur- 
nishes probably  some  material  which  enters  the  blood  through 
the  lymphatic  system,  which  is  essential  to  the  chemical  meta- 
bolism and  nutrition  of  the  tissues.  This  material  probably 
checks  a  tendency  to  auto-intoxication  by  destroying  poisons 
resulting  from  tissue  metabolism.  Giving  of  thyroid  affects 
the  nervous  system,  increasing  the  heart  beat,  yet  lowering 
arterial  tension.  The  respirations  are  increased  and  the  tem- 
perature is  not  constant.  Headaches  and  flushings  may  fol- 
low. The  intellect  usually  brightens,  the  appetite  increases, 
tissue  waste  increases,  showing  that  the  remedy  increases 
nitrogenous  waste  and  the  oxidation  of  the  fats.  The  urine 
show^s  no  decided  changes,  as  a  rule.  The  secretion  of  the 
thyroid  is  a  colloid.  Iodine  exists  in  the  thyroid  at  birth,  and 
increases  with  age.  Now.  on  general  principles,  thyroid,  act- 
ing as  has  been  described,  surely  should  not  be  given  in  dia- 
betes mellitus,  for,  among  other  things,  it  increases  the  com- 
bustion of  fats  and  causes  a  loss  of  both  these  and  muscle 
tissue,  just  as  diabetes  does. 

463 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Hear  what  Dr.  William  Murrell  says.  His  patient  was  a 
woman,  with  diabetes  of  probably  neurotic  origin,  arising 
from  vasomotor  paralysis,  increasing  the  blood-supply  to  the 
liver,  kidneys,  etc.  In  twenty-four  hours  she  passed  one  hun- 
dred and  twelve  ounces  of  urine,  containing  over  twelve 
ounces  of  sugar,  being  over  fifty-two  grains  to  the  ounce,  a 
very  large  amount.  This  was  the  average  for  fourteen  days. 
Murrell  rightly  says  that  what  we  want  is  a  drug  that  will 
get  rid  of  the  sugar  from  the  urine,  and  yet  not  restrict  the 
supply  of  carbohydrates  to  the  patient.  The  pancreas  could 
only  be  useful  in  cases  of  pancreatic  diabetes.  He  gave  in- 
creasing doses,  up  to  twelve  grains,  of  fresh  thyroid  every 
three  hours,  some  inconvenience  being  noted,  until  tolerance 
was  established.  The  appetite  was  good,  and  she  ate  ordi- 
nary diet, — bread  and  butter,  meat,  milk,  potatoes,  tea,  gruel, 
etc.  She  practically  ate  what  she  craved.  Under  this  treat- 
ment, from  over  twelve  ounces  of  sugar  daily  she  came  down 
to  a  little  over  six  ounces,  and  in  eleven  days  more  to  less 
than  three  ounces.  Now  thyroid  treatment  was  stopped  and 
the  patient  dieted,  and  she  got  only  fish,  beef,  tea,  milk,  and 
a  little  toast.  The  result  was,  she  passed  two  thousand  two 
hundred  and  sixty  grains  more  sugar  daily  on  a  restricted 
diet  than  she  did  on  a  full  diet  plus  thyroid  treatment. 

How  did  the  thyroid  act  ?  Thyroid  contains  colloid  matter 
and  a  small  quantity  of  nucleo-albumin  and  extractives.  It 
hastens  cell  action,  it  increases  oxidation  of  the  tissues,  it 
destroys  the  circulating  proteid,  and  increases  nitrogenous 
waste ;  so,  in  treating  obesity  with  it,  the  diet  should  not  be 
restricted.  Plenty  of  nitrogen  especially  should  be  taken.  If 
we  accept  Pavy's  theory,  that  glycogen  is  converted  into  fat, 
we  get  a  clue  to  the  action  of  thyroid  in  helping  diabetes  mel- 
litus.  We  only  know,  says  Murrell,  that  in  some  cases  thy- 
roid lessens  the  amount  of  urine  and  the  sugar  excreted  with 
it,  and  at  the  same  time  reduces  the  body  weight.  It  will  es- 
pecially suit  cases  in  elderly  people  in  which  obesity  is  a 
prominent  feature.  This  is  encouraging,  contradictory  as  it 
appears,  and  will  teach  us  to  watch  for  such  cases,  and  will 

464 


FORTY   YEARS    IN    THE   MEDICAL    PROFESSION 

further  teach  us  that  there  is  no  empirical  way  to  treat  dia- 
betes, nor,  in  fact,  other  diseases,  but  that  every  case  must  be 
a  study,  not  more  as  to  its  idiosyncrasies  than  as  to  its  physio- 
logical and  pathological  peculiarities.  Remember  that  in  dia- 
betes, probably  not  only  is  the  oxidation  of  carljohydrates 
restricted,  but  their  conversion  into  fats  is  equally  restricted, 
and  glycosuria  can  only  folhnv  possibly  when  the  fat-forming 
cells  and  the  oxidizing  cells  both  cease  to  arrest  the  sugar 
molecule. 

I  have  seen  quite  a  number  of  cases  of  diabetes  mellitus, 
and  the  rapid  cases,  as  a  rule,  have  been  under  thirty  years 
of  age,  and  tuberculosis  has  been  the  ending  of  mcjst  of  them. 
I  do  not  remember  a  case  to  have  ended  by  pulmonary  tuber- 
culosis after  thirty  years  of  age.  The  most  chronic  and  man- 
ageable cases  were  those  in  men  after  middle  age,  and  a 
coexistence  of  gout  appeared  to  prolong  life,  yet  the  conven- 
tional diets  of  gout  and  diabetes  are  apparently  so  opposed. 
They  are  not  so  opposed,  for  the  gouty  patient  is  quite  tolerant 
of  carbohydrates.  Study  his  case,  and  coax  him  and  watch 
him,  and  he  will  usually  respond.  Serious  accidents  to  dia- 
betics, and  surgical  operations  and  shocks  of  all  kinds,  are 
most  unfortunate.  I  have  seen  no  reason  to  believe  it  to  be 
contagious,  but  many  instances  have  been  offered  to  prove 
such  to  be  the  case.  That  bacterial  influences  affect  it  greatly, 
if  they  do  not  cause  it  altogether,  at  least  in  some  forms,  im- 
presses me  gravely.  As  before  stated,  I  have  seen  it  in  the 
negro,  Jews  are  said  to  suffer  from  it  in  a  larger  percentage 
than  any  other  race.  They  lead  active  lives  mentally,  slug- 
gish lives  physically,  as  a  rule,  and  are  great  eaters  of  the 
carbohydrates.  My  experience  leads  me  to  believe  diabetes 
is  hereditary  in  many  cases,  and  members  of  such  families 
should  be  warned  of  the  possible  bad  eft'ects  of  high  living 
and  the  excessive  use  of  carbohydrates,  and  to  especially 
avoid,  as  far  as  poor  mortals  can,  over-work  and  wear  and 
tear,  for,  remember,  it  comes  in  various  forms,  and  the  neu- 
rogenous form  is  a  common  form.  Syphilis  may  be  a  factor, 
particularly  through  the  brain,  the  blood-vessels,  or  the  pan- 
30  465 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

creas.  Take  it  into  account  in  your  differentiation.  If  you 
can  make  out  a  pancreatic  case,  above  all  things  use  pancre- 
atic preparations,  although  experience  does  not  yet  give  you 
great  encouragement  in  that  line. 

Von  Noorden's  suggestions  as  to  diet  and  general  treat- 
ment are  golden.  If  your  diet  is  too  low,  the  albumin  and 
the  fat  both  go.  The  diet  of  the  diabetic  man  must  give  him 
at  least  thirty-five  calories  per  kilogram  of  weight  per  day. 
The  average  for  a  healthy  man  is  two  thousand  five  hundred 
calories  per  day.  A  healthy  man  takes  in  his  diet  forty  per 
cent,  of  carbohydrates.  In  a  diabetic  most  of  this  goes  away 
in  the  urine,  and  does  him  no  good.  The  more  carbohydrates 
he  can  tolerate,  the  better  for  him.  Some  tolerate  more,  some 
less,  and  the  last  are  the  most  difficult  cases  to  treat.  To  find 
out  this  tolerance  in  your  patient  is  one  of  your  first  duties. 
The  worse  the  diabetes,  the  more  proteids,  fats,  and  alcohol 
we  must  use.  Among  the  best  forms  of  the  carbohydrates 
are  fruit-sugar,  milk-sugar,  and  cane-sugar.  Now  and  again 
rest  the  sugar-consuming  cells  by  withholding  the  carbohy- 
drates. Get  the  tolerance  of  the  patient  to  carbohydrates  by 
the  amount  of  sugar  in  the  urine,  always  taking  into  consid- 
eration the  diet  being  used.  Bread  and  potatoes  are  more 
difficult  to  abstain  from  than  sugar  or  wines. 

I  had  once  a  dear  friend  who  died  of  diabetes.  He  was  an 
able  man,  and  had  held  distinguished  positions,  but  dieting 
was  very  difficult  with  his  diabetic  appetite.  I  have  seen  him 
eat  a  dinner,  indulging  in  every  compound  on  general  prin- 
ciples injurious  to  one  in  his  condition.  After  dinner  he 
would,  with  a  good  deal  of  grace  of  manner,  decline  sugar 
in  his  coffee:   "  Can't  take  it ;   my  doctor  forbids  it." 

So  it  is  with  a  great  many,  indeed  perhaps  with  the  ma- 
jority; they  knowingly  cheat  themselves.  Study  your  pa- 
tient, and  calculate  the  number  of  calories  necessary  for  his 
proper  existence.  He  may  need  two  thousand  five  hundred, 
and  get  by  his  diet  and  loss  through  his  disease  only  fifteen 
liundred.  He  will  get  weak  and  thin,  his  fat  and  strength 
going  with  his  muscles.     Now  look  out  for  failure  at  the 

466 


FORTY   YEARS    IN    THE    MEDICAL    PROFESSION 

heart,  coma,  and  such  troubles.  Give  oceans  of  fat.  Fat  is 
a  great  factor  in  the  average  diabetic.  Alcohol  will  help  the 
fat,  it  gives  fuel,  but  study  the  quantity  each  case  may  need. 
Too  much  may  poison  the  protoplasm  of  the  cells,  and  thus 
tissue  waste  and  tissue  destruction  may  go  on  more  rapidly 
to  the  disadvantage  of  the  patient. 

Remember,  though,  in  serious  progressive  cases  after  a 
while  even  the  fats  break  up  and  increase  the  elimination  of 
sugar.  See  how  complex  are  these  cases,  and  what  tact  and 
watching  they  require.  Exercise  short  of  fatigue  consumes 
sugar,  and  is  therefore  to  be  recommended.  Fatigue  in  any 
shape  or  from  any  cause  is  bad.  Massage  is  passive  exercise, 
and  even  approaches  active  work.  Von  Noorden's  rest  plan 
is  the  proper  plan  of  treating  almost  every  case  of  diabetes 
mellitus.  If  your  case  is  a  moderate  one,  and  you  have  gotten 
its  carbohydrate  tolerance,  rest  the  sugar-consuming  cells  for 
three  weeks  in  every  three  months,  at  least.  If  the  case  is  a 
serious  one,  rest  it  absolutely  one  month  in  every  three  months. 
Every  case  is  a  study.  Resting  these  cases  makes  them  much 
more  tolerant  of  the  carbohydrates  when  they  commence  them 
again.  A  milk  diet  is  near  absolute  rest.  One  litre  of  milk 
equals  fifty  grammes  of  bread.  Rest  diet  must  be  a  diet  as 
free  as  possible  of  every  form  of  carbohydrates.  Give  lots  of 
fat.  One  hundred  grammes  of  aleuronat  bread  equal  fifty 
grammes  of  wheat  bread.  Ninety  grammes  of  potatoes  equal 
twenty-five  grammes  of  w^heat  bread.  Beware  of  intestinal 
catarrhal  troubles.  They  are  dangerous.  Let  up  on  the  solid 
foods.  Take  milk,  spirits,  etc.  The  prognosis  in  all  cases  of 
diabetes  depends  on  many  factors.  The  physical  peculiarities 
of  the  patient  count  much ;  family  history  counts  much : 
the  mental  characteristics  of  the  patient  count  much ;  the 
circumstances  of  the  patient  count  much,  as  well  as  his  em- 
ployment and  his  environment.  The  blood-count  and  color- 
test  of  the  blood  tell  much.  The  age  of  the  patient  counts 
much.  Syphilitic  cases  and  obese  cases  are  most  amenable 
to  treatment.  Tall,  spare,  weak  people  are  particularly  vul- 
nerable. 

467 


FORTY   YEARS    IN    THE   MEDICAL    PROFESSION 

After  all,  the  waste  of  the  nitrogenous  matters,  as  indi- 
cated b}^  the  amount  of  urea  passing  off  by  the  urine,  is  the 
factor  that  counts  more  than  any  other,  and  this  is  the  factor 
which  determines  the  difference  between  a  true  diabetes  and 
a  mere  glycosuria.  The  one  is  usually  permanent,  the  other 
may  be  only  temporary.  The  physician  in  the  case  counts 
probably  more  than  any  one  factor.  Without  intelligent  ad- 
vice, the  diabetic,  as  a  rule,  goes  rapidly  to  destruction. 

As  said  before,  we  must  learn  to  distinguish  between  true 
glycosuria  and  true  diabetes.  The  true  diabetic  usually  has 
a  voracious  appetite,  and  he  invariably,  under  such  conditions, 
eats  too  much.  So  much  sugar  passes  off  in  his  urine  that 
he  must  have  starches  as  the  material  from  which  to  replace 
it,  and  he  thus  craves  carbohydrates,  and  the  trouble  in  prac- 
tice is,  few  can  resist  this  craving.  As  a  result  of  this  over- 
indulgence, fermentation  of  food  takes  place  after  it  has  been 
eaten.  These  patients  are  always  in  great  danger,  for  most 
of  them  will  over-indulge,  and  an  excessive  meal  of  carbohy- 
drates, combined,  I  think,  particularly  with  shell-fish  and 
such  glycogenic  foods,  is  often  followed  by  severe  attacks 
of  acute  indigestion  and  sudden  death,  for  these  unfortunates 
have  so  little  vitality,  so  little  ability  to  resist  the  attacks  of 
any  disease,  as  to  make  them  particularly  vulnerable  to  even 
moderate  onslaughts.  Such  patients  should  be  particularly 
watched  and  prevailed  upon  to  reduce  the  excessive  quantity 
of  all  foods,  and  especially  of  carbohydrates  and  other  sugar- 
producing  materials.  Such  cases  usually  need  lavage  of  both 
stomach  and  bowels,  with  such  antiferments  by  the  mouth  as 
hydrogen  dioxide,  the  salicylates,  with  antipyrin  and  bicarbo- 
nates  of  soda  and  potash  if  the  heart  be  not  too  weak.  Scotch 
whiskey  or  gin,  very  largely  diluted  with  water  and  taken 
regularly,  is  most  useful  in  such  cases;  in  fact,  alcohol  is  a 
wonderful  remedy  here.  In  case  the  plan  of  withdrawing  all 
liquids  is  tried,  a  little  spirit  will  make  this  plan  more  bearable 
to  the  patient.  It  is  in  these  cases  we  may  look  for  some  pre- 
monition of  the  skin  of  a  bronze  hue.  This  comes  from 
destruction  of  the  haemoglobin.     The  excess  of  sugar  causes 

468 


FORTY    YRARS    IN    THE    MF^DICAL    PROFRSSfON 

dilution  of  the  blood.  It  has  been  suggested  that  this  sets 
free  some  of  the  haemoglobin,  and  this  is  changed  and  depos- 
ited in  the  tissues  and  causes  the  bronze  pigmentation.  Cir- 
rhosis of  the  liver  may  occur  in  these  cases. 

Now,  as  to  other  remedies  valuable  in  the  treatment  of  dia- 
betes mellitus.  Arsenic  has  been  used  for  a  long  time,  on  the 
theory  that  it  has  some  specific  action  on  the  digestive  tract, 
and  that  it  increases  the  oxidizing  power  of  the  red  blood- 
corpuscles  over  grape-sugar.  My  experience  with  arsenic  has 
led  me  to  abandon  it.  I  doubt  if  it  has  any  virtue  whatever 
beyond  its  general  tonic  properties.  Dr.  Barney  recom- 
mends the  double  bromides  of  gold  and  arsenic  in  five-drop 
doses  after  each  meal,  increasing  one  drop  each  day  until 
tolerance  ceases.  In  syphilitic  cases  the  indications  are 
plain.  Use  mercury  and  the  iodides,  being  careful  of  mer- 
cury. Opium  and  its  salts  have  long  held  a  reputation  in 
the  treatment  of  diabetes.  They  probably  act  by  locking 
up  the  secretions,  and  there  must  be  some  specific  action 
in  them  over  the  formation  or  the  destruction  of  the  sugar. 
I  am  afraid  of  opium  in  chronic  diseases  as  a  general  thing, 
it  is  so  horribly  demoralizing.  Of  the  salts,  codeine  is  the 
least  objectionable  in  most  ways.  It  really  appears  to 
control  the  sugar  in  some  way,  but  I  think  I  know  of  better 
remedies,  and  hence  I  rarely  if  ever  use  it.  It  is  said  to  do 
better  given  with  hydrogen  dioxide.  The  alkalies  have  been 
used  much.  It  is  claimed  that  they  destroy  the  sugar  in  the 
blood  and  neutralize  volatile  acids.  They  may  be  useful  in 
conditions  approaching  coma,  which  we  have  already  spoken 
of.  In  gouty  cases  the  salicylates  are  useful,  and  in  the  neu- 
rogenous form  they  quiet  the  nerves.  Ergot  and  lactic  acid 
have  been  much  recommended.  I  see  no  reason  to  use  them 
except  in  special  emergencies  that  may  arise.  Fats  are  at 
times  most  useful,  and  especially  in  those  cases  where  all,  or 
nearly  all,  of  the  carbohydrates  are  converted  into  glucose 
and  excreted,  and  the  body  is  encroaching  on  its  own  pro- 
teids  for  power,  consuming  its  own  tissues.  Here  give  cod- 
liver  oil  and  whiskey.     Slush  the  system  with  it,   and  let 

469 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

the  patient  eat  fat  in  all  conceivable  shapes.  Help  its  as- 
similation with  spirits,  and  so  long  as  they  agree  and  have 
a  good  effect,  eat  fats  and  drink  spirits. 

Upon  the  theory  that  brewer's  yeast  would  excite  vinous 
and  acetous  fermentation  in  the  stomach,  and  thus  convert 
the  excess  of  sugar  there  into  acetic  acid,  Dr.  George  B. 
Wood  years  ago  recommended  yeast.  I  have  used  it  with 
little  or  no  benefit,  a  tablespoonful  three  times  a  day.  On 
the  theory  that  the  yeast-plant  might  be  antagonistic  to  cer- 
tain pathogenic  bacteria,  I  have  used  it  locally  and  constitu- 
tionally in  diphtheria,  with  apparently  good  results. 

Dr.  James  Gray,  of  Glasgow,  gave  rennet,  to  change  the 
sugar  into  lactic  acid,  with  repeated  good  result.  Phenacetin 
and  other  coal-tar  derivatives  are  said  to  do  good  at  times. 
I  have  had  little  experience  with  them.  They  slow  the  pulse, 
and  possibly  have  more  or  less  effect  on  assimilation  and 
tissue  change. 

For  eczemas  and  the  different  forms  of  pruritus  encoun- 
tered among  diabetics,  absolute  cleanliness  and  the  applica- 
tion of  chloral  washes  are  the  best  remedies.  Chloral,  ten  to 
twenty  grains  to  the  ounce,  makes  a  good  wash.  A  strong 
solution,  sixty  grains  or  more  to  the  ounce,  is  said  by  good 
authority  to  be  almost  a  specific  in  rhus  toxicodendron  poison- 
ing. 

There  are  two  remedies  from  which  I  have  had  recently 
most  remarkable  results  in  reducing  the  sugar  in  cases  of 
diabetes  mellitus.  I  refer  to  the  fluid  extract  of  the  seeds  of 
jambul.  Botanically  it  is  Jamhoo  syzygium  jmnholanum, 
Java  plum.  It  grows  in  the  East  Indies  generally.  The  wood 
yields  a  brown  dye.  The  berry  is  olive-shaped  to  globose, 
from  the  size  of  a  pea  to  that  of  a  pigeon's  tgg,  and  black 
when  ripe.  It  contains  one  seed  enclosed  in  a  thin  white  shell. 
Experiment  proves  that  it  prevents  the  conversion  of  starch 
into  sugar.  In  ten-drop  doses  three  times  a  day  in  all  forms 
of  diabetes  mellitus  except  the  pancreatic  form,  in  which  I 
have  not  had  an  opportunity  to  use  it,  it  has  been  very  effec- 
tual in  reducing  the  sugar,  but  has  never  absolutely  eradicated 

470 


FORTY    YEARS    IN    TIN'.    M IIUICAL    PROFESSION 

it  from  the  urine.  The  other  remedy  is  piperazine,  the  use  of 
which  I  have  before  spoken  of  in  renal  calculus  and  gouty 
affections.  Piperazine  has  acted  with  me  just  as  jambul  has 
acted  in  reducing  the  amount  of  sugar  in  the  urine.  It  is  rap- 
idly absorbed  and  passes  rapidly  through  the  kidneys,  pro- 
ducing a  reddish-brown  urine.  This  is  not  so  marked  in 
diabetes  until  it  has  been  taken  several  days  and  reduced  the 
amount  of  urine.  It  checks  the  saccharifying  influence  of 
haemic  and  other  hydrolytic  ferments,  yet  has  no  destroying 
influence.    It  checks  diabetes  produced  by  phloridzin. 

Here  is  an  interesting  point,  and  points  again  to  the  kid- 
ney as  a  possible  factor  in  diabetes  mellitus.  It  is  in  regard 
to  the  combined  action  of  these  medicines  that  I  have  a  word 
to  say.  I  have  in  several  cases  given  ten  drops  of  the  fluid 
extract  of  jambul  seed  in  a  tablespoonful  of  solution  of  piper- 
azine, containing  twenty  per  cent,  of  alcohol,  in  which  were 
five  grains  of  piperazine,  the  patient  being  ordered  to  take  it 
in  a  half-pint  of  plain  water.  I  have  only  to  say  that  so  far 
the  results  have  been  wonderful,  and  give  me  great  encour- 
agement in  the  treatment  of  this  intractable  disease. 

During  the  treatment  all  diets  were  used,  and  a  moderate 
amount  of  carbohydrates  does  not  appear  to  seriously  affect 
the  gratifying  results,  and  the  patient  thrives  and  is  kept  in 
good  humor.  It  is  scarcely  necessary  to  say  that  all  the  rules 
of  hygiene  should  be  observed  by  the  diabetic,  and  under  the 
surveillance  of  his  medical  adviser  he  should  lead  the  life  of  a 
good  citizen,  clean  and  clear  in  mind  and  body. 

Now  as  to  the  all-important  matter  of  diet.  This  has  al- 
ready been  gone  over  pretty  thoroughly  as  to  its  chemical  and 
physiological  attributes,  and  it  only  remains  to  consider  the 
practical  points,  and  show  the  foods  fit  for  the  sufferer 
from  diabetes  mellitus,  arranged  according  to  their  chemical 
compositions  and  physiological  action.  Here,  again,  comes 
in  individuality  and  the  specific  case  you  are  advising.  You 
cannot  lay  down  a  diet  for  all  cases.  You  can  only  give  cer- 
tain general  rules,  and  tell  the  virtues  and  vices  of  certain 
articles  in  the  lists  you  may  see  fit  to  present.     The  great 

471 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

divisions  from  which  you  are  to  choose  are  the  carbohydrates, 
the  albuminoids,  and  the  fats. 

Substitutes  for  Sugar. — It  is  not  difficult,  as  a  rule,  for  one 
to  give  up  sugar  in  coffee  and  tea,  but  in  diet  generally  it  is 
difficult  to  do  without  it,  and  we  need  some  substitute  for 
the  diabetic  to  use  more  or  less  freely,  and  yet  not  affect  his 
condition  unfavorably.  Saccharin  is  a  crystalline  nitrogenous 
body  derived  from  coal-tar.  One-half  grain  of  it  will  sweeten 
a  cup  of  coffee.  A  tablet  composed  of  one-seventh  of  a  grain 
of  saccharin,  one-third  of  a  grain  of  sodium  bicarbonate,  and 
eight  grains  of  mannite  will  sweeten  a  cupful  of  any  drink. 
It  is  not  very  soluble  in  cold  water,  more  so  in  hot  water,  and 
quite  soluble  in  glycerin.  It  is  three  hundred  times  sweeter 
than  cane-sugar.  Two  grains  a  day  may  be  taken  for  a  long 
time.  It  is  antiseptic,  has  the  property  of  rendering  the  urine 
acid,  and  is  eliminated  unaltered  by  the  kidneys,  hence  its 
harmlessness  in  many  cases  of  diabetes,  yet  from  its  antifer- 
ment  action  it  may  disturb  digestion  at  times.  Saccharin 
present  to  the  amount  of  one  per  cent,  in  pancreatic  solutions 
lessens  their  activity.  It  should  not  be  used  in  pancreatic 
diabetes,  and  I  am  not  much  in  favor  of  it  in  diabetes  gen- 
erally. Mannite  may  be  used.  It  is  the  active  crystalline 
principle  of  manna.  It  does  not  contain  equal  parts  of  hydro- 
gen and  oxygen,  and  is  not,  therefore,  easily  converted  into 
grape-sugar  or  alcohol.  Fruit-sugar,  levulose,  sold  under 
the  name  of  Diabetin,  is  probably  the  best  sugar  for  the  dia- 
betic if  used  alone.  It  is  not  known  to  reappear  in  the  urine. 
It  does  not  disorder  digestion.  It  is  sweeter  than  cane-sugar 
and  is  fruity  in  its  taste.  Lactose  or  lactin,  or  sugar  of  milk, 
is  more  expensive  than  cane-sugar  and  not  so  sweet.  It  is  a 
form  of  carbohydrate  easy  to  assimilate,  but  is  not  to  be 
recommended  in  diabetes,  yet  it  does  not  appear  to  render 
milk  objectionable  in  that  disease.  Glycerin  may  be  used  by 
those  who  can  take  it.  It  often  disorders  digestion  and  causes 
looseness  of  the  bowels.  The  only  cases  in  which  I  use  it  are 
where  the  bowels  are  obstinately  constipated,  as  we  often  find 
them  when  the  patient  is  on  absolute  diet. 

472 


FORTY    YEARS    IN    Till'     Mi:i;lCAL    PROFESSION 

Drinks. — There  is  often  great  thirst,  so  much  of  the  body 
fluids  going  off  by  the  kidneys.  Plain  water,  or  water  slightly 
acidulated  with  a  few  drops  of  dilute  phosphoric  acid  or 
lemon-juice,  or  with  a  pinch  of  bicarbonate  of  soda  or  potash, 
is  best.  The  effervescing  waters  are  grateful  to  many,  per- 
fectly plain.  The  alkaline  spring  waters,  such  as  Vichy  and 
the  Saratoga  waters,  are  most  grateful  and  useful.  Saratoga 
Vichy,  Saratoga  Kissingen,  and  Saratoga  Carlsbad  are  the 
best.  As  to  spirits,  uncolored  California  brandy  and  Scotch 
whiskey  are  the  better.  Colored  spirits  have  more  or  less 
sugar  in  the  coloring-matter.  Claret  is  the  best  wine.  The 
Rhine  wines  come  next.  Sparkling  wines  are  poison  from 
the  sugar  they  contain.  The  best  sparkling  drink  is  brandy, 
whiskey,  claret,  or  Rhine  wine  in  soda-water.  These  are 
almost  as  palatable  as  champagne,  and  better  than  some 
brands.  Malt  liquors  are  suicidal  to  the  diabetic.  If  he  must 
drink  them,  he  will  live  longest  on  those  long  bottled,  the 
sugar  having  gone  to  alcohol  and  carbonic  acid. 

There  are  foods  which  on  general  principles  should  not  be 
allowed  to  diabetics.  Such  include  syrups,  sweet  preserves, 
molasses  plain  or  compounded,  all  candies  and  jams.  Honey 
contains  dextrose  and  levulose,  but  I  think  the  harm  of  honey 
is  most  because  it  is  eaten  with  bread  or  other  carbohydrate. 
Breads  and  pastry  must  be  avoided ;  as  a  rule,  the  latter  are 
injurious  to  well  persons.  Tapioca,  arrow-root,  rice,  and 
sago  are  very  injurious.  All  articles  made  of  Indian  corn 
are  less  injurious  than  those  made  of  wheat,  but  nevertheless 
should  be  forbidden,  as  well  as  all  hot  breads  made  of  buck- 
wheat, barley,  and  such.  Oatmeal  is  nitrogenous,  but  has 
too  much  carbohydrates.  All  macaronis  in  the  market  are  as 
bad  as  wheat  flour,  as  we  shall  see  farther  on.  So  are  vermi- 
celli and  spaghetti.  The  white  potato  is  proscribed  by  most 
physicians.  For  absolute  diet  it  must  be  proscribed.  Where 
some  carbohydrates  are  allowable  it  furnishes  the  best  form 
for  them  if  well  baked.  It  has  only  about  twenty  per  cent, 
of  starch.  It  is  a  much-abused  carbohydrate  in  the  diets 
for  the  diabetic  and  obese,  if  used  well  baked  and  in  no  other 

473 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

way.  Of  course,  much  water  goes  off  in  baking,  but  the 
starch  is  better  broken  up.  CauHflower  has  more  carbohy- 
drates than  cabbage,  the  former  having  six  per  cent,  and  the 
latter  four  per  cent.  Cabbage  particularly  may  be  allowed 
raw  or  boiled  in  moderation.  I  speak  of  this  because  many 
diet  tables  disallow  it.  Parsnips,  carrots,  and  beets  are  better 
to  be  dropped  entirely.  All  beans  except  green  string-beans 
should  be  prohibited.  String-beans  have  only  about  nine  per 
cent,  of  carbohydrates;  other  beans  run  up  as  high  as  sev- 
enty per  cent,  when  dried.  Lima  beans,  green  only,  run 
twenty-two  per  cent.,  the  water  not  having  been  driven  off. 
Brussels  sprouts  may  be  eaten,  as  they  only  contain  about 
three  per  cent,  starch.  Most  diabetic  diet  tables  leave  them 
out.  Asparagus  is  on  an  equality  with  Brussels  sprouts.  Rhu- 
barb is  objected  to  in  most  diet  tables.  The  truth  is,  it  con- 
tains little  of  anything,  and  the  small  amount  of  oxalic  acid 
in  it  makes  it  very  grateful  in  the  early  spring.  I  should 
allow  a  little,  sweetened  with  saccharin  or  diabetin.  Clams, 
oysters,  and  mussels  have  glycogen  in  their  soft  parts,  be- 
cause these  soft  parts  are  their  livers.  I  think  they  should 
be  used  very  sparingly,  and  only  raw  or  plainly  cooked,  with 
no  flour.  For  the  same  reason  livers  of  all  animals  should 
be  shunned. 

Most  fruits  are  forbidden  in  a  majority  of  the  diabetic  diet 
tables.  This,  I  believe,  is  correct  as  applied  to  all  preserved 
fruits,  as  they  almost  invariably  contain  cane-sugar.  Apples 
and  pears  contain  only  about  ten  per  cent,  carbohydrates. 
Sometimes  we  have  to  allow  something  of  the  kind  to  appease 
cravings  and  regulate  the  bowels.  Apples  and  pears,  espe- 
cially the  tart  apples,  do  the  least  harm.  A  few  strawberries 
unsweetened,  or  sweetened  with  saccharin,  diabetin,  or  man- 
nite,  may  be  allowed,  or  watermelon,  ice  cold,  if  craved,  as 
each  only  has  about  six  per  cent,  carbohydrates.  Raspberries 
and  nectarines  are  more  objectionable.  Peaches  and  black- 
berries are  about  in  the  class  with  pears,  and  so  are  oranges. 
It  is  better,  as  a  rule,  to  avoid  them  and  lemons  too.  Mind 
you,  these  fruits  are  not  urged  as  diabetic  diet,  but  are  only 

474 


FORTY    YI'.AKS    IN    'I'llI'".    M\'.])\CA\.    l'K'Oi-l-:SSION 

given  here  to  let  us  out  of  a  (lileninia  .sometimes,  for  the  pa- 
tient may  cat  things  much  worse  if  curbed  too  much. 

Many  of  the  nuts  are  useful  as  food,  and  some  of  the  oily 
ones  especially  may  be  used  by  diabetics.  Chestnuts  are  away 
up  in  carbohydrates,  and  should  never  be  eaten  by  the  dia- 
betic. Peanuts  are  also  objectionable,  but  less  so  than  chest- 
nuts.    Cocoanut  is  also  objectionable. 

As  to  allowable  foods,  they  are  numerous,  but  even  with  all 
these  and  no  bread,  life  soon  becomes  a  burden,  and  in  many 
cases  confinement  to  the  list  is  unbearable.  All  soups  made 
without  the  addition  of  carbohydrates,  all  edible  fish,  reject- 
ing the  livers,  lobsters,  crabs,  and  shrimp,  and  about  all  of  the 
meats  may  be  used,  except  livers.  In  cooking  them  the  use 
of  carbohydrates  is  to  be  avoided.  Eggs  are  most  useful 
cooked  in  various  ways.  As  to  fats,  you  must  sound  your 
patient  as  to  tolerance  of  fats,  and  where  tolerated,  as  a  rule, 
for  reasons  before  given,  use  them  freely ;  they  save  albumin. 
If  the  patient  crave  fats,  encourage  the  taking  of  them  in  every 
conceivable  way.  Some  object  to  fats  on  the  ground  that  they 
form  glycerin.  There  is  no  good  reason  given  for  rejecting 
them  on  this  score.  As  to  butter,  it  is  among  the  best  of  the 
fats.  The  little  milk-sugar  it  may  contain  is  no  objection 
whatever. 

A  list  of  vegetables  allowable  is  given  here  for  convenience. 
Most  of  the  winter  and  spring  greens,  as  dandelion,  cabbage 
greens,  horse-radish,  spinach,  celery,  and  plenty  of  it,  okra, 
lettuce,  endives,  pickles,  kale,  cucumbers,  cranberries  sweet- 
ened with  saccharin,  levulose,  or  mannite,  string-beans,  which 
may  be  obtained  all  the  year,  fresh  or  canned.  The  soja  beans 
have  very  little  starch;  they  are  oily  and  unpleasant  dried, 
but  I  have  thought,  possibly,  we  may  get  a  good  green  ^■ege- 
table  from  them  by  using  them  half-grown  and  canning  them 
for  winter  use.  This  experiment  is  worth  trying  in  the  in- 
terest of  diabetics.  Asparagus  is  good  all  the  year  round, 
fresh  or  canned.  Of  all  vegetables,  asparagus  is  least  afifected 
in  flavor  or  otherwise  by  canning.  Onions  are  debatable  food. 
The  Bermuda  onion  contains  too  much  sugar,  undoubtedly, 

475 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

and  so  do  parsnips  and  carrots.  Egg-plant  may  be  used 
sparingly,  if  we  are  put  to  it  for  a  change.  It  must  not  be 
cooked  with  carbohydrates,  and  without  these  it  is  Hke  pud- 
ding without  sauce. 

Thompson  quotes  Fagge  as  saying,  "  As  a  rule,  all  white 
parts  of  vegetables  in  which  chlorophyll  has  not  been  devel- 
oped by  exposure  to  sunlight  contain  no  sugar.  Boil  all 
kinds  of  forbidden  vegetables  in  much  water,  and  if  they  con- 
tain only  sugar  and  not  starch,  much  of  their  sugar  will  be 
lost,  and  they  may  be  eaten  by  the  diabetic.  Beets  are  in 
this  class,  but  I  am  very  doubtful  as  to  beets  being  under  any 
conditions  good  food  for  the  diabetic." 

Mushrooms  have  a  little  grape-sugar,  but  so  little  that  they 
may  be  eaten  freely  by  the  diabetic.  The  French  morel  has 
a  mere  trace,  and  the  truffle  has  none.  These  are  great  helps 
for  their  flavor,  and  are  often  great  additions  to  steaks,  pig's 
feet,  tripe,  kidneys,  sweet-breads,  and  such. 

The  diabetic  may  eat  terrapin,  a  dish  for  the  gods.  "  Good 
wine  needs  no  ivy-bush."  Terrapin  needs  no  sauce.  The 
only  restriction  is,  be  chary  of  the  liver.  Butter,  pepper,  and 
salt  are  all  that  are  necessary  to  bring  out  the  flavor  of  terra- 
pin, and  this  is  the  diabetic's  way  to  eat  it.  Corn-starch, 
flour,  and  Madeira  or  sherry  only  take  away  from  its  natural 
gout.  If  you  must  have  wine,  use  a  dry  Madeira  or  sherry. 
Madeira  is  the  gentleman's  wine  for  terrapin,  one  glass  to 
one  count  terrapin.  Sherry  is  a  good  second  in  the  same  pro- 
portion. 

Milk. — Here  comes  up  an  important  question  in  the  diet 
for  diabetics, — the  use  of  milk.  Of  course,  I  refer  to  cow's 
milk.  In  looo  parts  of  fresh  milk  we  get  water,  873 ;  butter, 
30;  casein,  48.20 ;  sugar  of  milk,  43.90;  calcium  phosphate, 
2.31;  iron  phosphate,  .7;  potassium  chloride,  1.44;  sodium 
chloride,  .24;  magnesium  phosphate,  .42;  compound  of  so- 
dium and  casein,  .42.  Milk  is  a  complete  food  and  will  sup- 
port life.  There  is  little  fecal  residue,  and  it  is  often  necessary 
to  add  lime-water,  or  some  alkali,  to  prevent  coagula  in  the 
stomach  when  a  patient  is  living  on  it  alone.     The  scum  of 

476 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

boiled  or  heated  milk  is  fnjni  the  albuminoids  of  the  milk, 
and  skimming  this  off  renders  the  milk,  of  course,  weak  as  a 
nitrogenous  food.  There  are  about  one  and  a  quarter  ounces 
of  fat  in  a  quart  of  average  whole  milk.  Casein  is  the  source 
of  albumin  in  milk,  and  very  much  resembles  animal  albumin. 
The  fat  of  milk,  the  cream,  is  olein,  palmitin,  butyrin,  caproin, 
and  caprin.  It  owes  its  peculiar  odor  to  the  latter.  Butyrin 
is  a  compound  ether,  butyric  acid  and  glyceryl.  Exposure  to 
the  air  renders  butter  rancid  by  decomposing  the  butyrate  of 
glyceryl  and  setting  butyric  acid  free. 

The  sugar  is  the  important  matter  in  milk  to  be  considered 
for  the  diabetic.  It  is  a  crystallized  sugar  obtained  from  the 
whey  by  evaporation.  Whole  milk  contains  about  five  per 
cent,  of  sugar  of  milk.  In  whole  average  milk  Atwater  and 
Woods  give  the  carbohydrates  as  only  2.3,  and  in  average 
skim-milk  as  2.2.  Of  course,  these  come  principally  from  the 
milk-sugar.  I  believe  milk  to  be  a  most  important  article  of 
diet  in  diabetes  mellitus.  It  is  rich  in  nitrogen  and  fat.  These 
come  from  the  globule  chiefly.  The  corpuscles  are  fat,  sur- 
rounded with  a  delicate  albuminoid  coating.  The  fat  here 
makes  the  butter,  the  corpuscle  being  broken  by  churning, 
and  letting  it  out.  I  believe  this  is  the  general  idea.  Senator 
thinks  the  milk-sugar  in  milk  does  not  increase  the  glycosuria, 
as  a  rule,  although  some  are  more  tolerant  than  others  of 
the  carbohydrate.  Tyson  thinks  it  more  difficult  to  pass  into 
grape-sugar  than  any  other  of  the  carbohydrates.  These  are 
matters  of  clinical  experience  only,  and  my  own  experience 
conforms  to  these  conclusions. 

The  time  comes  in  any  case  of  diabetes  mellitus  when  it  is 
proper  and  even  necessary  to  rest  your  patient  from  mixed 
diet;  to  rest  him  from  the  carbohydrates,  even  if  he  tolerates 
them  to  a  certain  extent.  Here  you  have,  with  which  to  ac- 
complish this,  a  resort  to  whole  milk,  to  skim-milk,  and  to 
predigested,  peptonized,  or  pancreatized  milk,  koumiss,  and 
buttermilk.  In  koumiss  the  milk-sugar  has  been  converted 
into  alcohol,  and  is  not  there  to  vex  your  patient.  In  butter- 
milk it  has  been  converted  into  lactic  acid.    These  two  articles 

477 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

are  in  every  way  a  very  great  help  in  the  diabetic  regimen, 
and  should  be  stand-bys  in  every  case.  They  are  grateful, 
refreshing,  and  in  every  way  acceptable. 

You  may  find  a  patient  who  cannot  take  the  little  carbo- 
hydrates in  milk  even,  and  so  in  other  forms  patients  vary  as 
to  their  capacity.  The  sugar  metabolic  limit  must  be  found 
in  these  cases  by  examining  the  urine.  The  rest-cure  leads 
to  the  recuperation  of  the  faculty  of  the  system  to  absorb 
sugar,  thus  checking  under-consumption,  and  yet  does  not 
kill  the  patient  by  feeding  him  exclusively  on  albumin  too 
long  a  time,  and  thus  rendering  his  blood  too  acid,  and  causing 
him  to  consume  his  own  tissues  beyond  the  endurance  of  life. 
Never  let  your  patient  overstep  his  carbohydrate  tolerance. 
If  the  patient  needs  fat  and  albumin  especially,  I  see  no  objec- 
tion to  Devonshire  cream.  This  is  taken  from  heated  milk, 
thus  skimming  both  the  cream  and  albumin. 

Tubes  for  peptonizing  or  pancreatizing  milk  may  be  pur- 
chased at  the  drug-shops  with  full  directions.  Horatio 
Wood's  directions  are :  Dilute  a  quart  of  milk  with  four 
ounces  of  water,  heat  to  140°  F.,  adding  two  teaspoonfuls 
of  Roberts's  liquor  pancreaticus,  with  twenty  grains  of  bi- 
carbonate of  sodium,  digesting  in  a  warm  place  for  an  hour 
to  an  hour  and  a  half,  and  raising  for  a  moment  to  the  boiling- 
point.  Another  receipt  is  to  dissolve  five  grains  of  pancreatin 
with  twenty  grains  of  bicarbonate  of  sodium  in  one  ounce  of 
warm  water;  add  this  to  one  pint  of  new  milk,  and  keep  at 
a  temperature  of  110°  F.  for  one  hour.  It  will  be  less  bitter 
and  probably  equally  effectual  if  only  left  a  half-hour.  In 
pancreatic  diabetes  I  look  upon  these  preparations  as  almost 
indispensable  in  diet. 

I  have  spoken  of  the  rest-treatment  of  diabetes,  the  rest 
from  everything  containing  carbohydrates  for  three  or  four 
weeks  in  every  three  months.  Take  a  case  of  a  man  who  will 
not  diet,  as  a  rule,  one  who  takes  a  drinking-bout  now  and 
again,  eats  and  drinks  everything,  and  is  in  the  greatest 
danger  of  a  sudden  ending  by  coma,  cerebral  hemorrhage, 
or  heart  failure  from  exhaustion.     After  a  bout,  particularly, 

478 


FORTY    YEARS    IN    Till':    MPLDICAL    PROFESSION 

these  men  are  quite  pious,  ([uite  virtuous  and  docile,  and  ready- 
to  take  advice.  Milk  is  tlie  great  food  with  which  to  com- 
mence the  treatment,  skini-niilk,  pancreatized  milk,  or  whole 
milk  Pasteurized,  aided,  if  you  choose,  hy  koumiss  or  butter- 
milk. Gradually  increase  the  diet,  and  in  three  or  four  weeks 
you  see  usually  wonderful  improvement.  In  your  discreet 
and  bidable  patients  the  same  course  once  a  quarter  will  rest 
them  greatly.  Alcohol  in  proper  proportions  assists  the  milk 
wonderfully  and  adds  to  the  tolerance  of  the  system  for  car- 
bohydrates. Upon  the  theory  that  uric  acid  diathesis,  oxalu- 
ria,  and  diabetes  are  different  phases  of  one  single  morbific 
entity,  Dr.  Lupa  went  on  an  anti-uric-acid  diet,  as  he  termed 
it,  and  ate  all  vegetables,  excluding  all  meats  and  such  nitro- 
genous foods.  He  claimed  great  success  in  his  own  and  other 
cases  of  diabetes.  Theory  is  against  this  method,  and  yet 
theory  does  not  always  avail  to  stop  a  good  thing. 

"  Bread  is  the  staff  of  life,"  and  the  staff  of  life  is  the 
one  thing  the  diabetic  needs  to  satisfy  his  craving.  Unfor- 
tunately, all  breads,  whilst  nearly  complete  foods,  have  for 
their  chief  ingredients  carbohydrates,  and  these,  as  a  rule, 
are  poison,  death,  and  destruction  to  the  diabetic.  Palatable 
substitutes  are  difficult,  almost  impossible,  to  get,  unless  they 
transgress  in  the  rule  as  to  carbohydrates.  Our  main  reliance 
is  to  be  placed  in  flours  in  which  more  or  less  of  the  starch 
has  been  washed  out,  leaving  chiefly  the  gluten,  and  in  flours 
made  from  vegetable  matter  which  in  nature  is  comparatively 
low  in  starch  and  sugar.  The  former  are  known  in  the  mar- 
ket as  "  gluten  flours,"  and  the  latter  have  special  names, 
according  to  what  they  may  be  made  of,  or  the  party  manu- 
facturing them. 

Let  us  take  up  "  gluten  flour."  Through  the  kindness  of 
Dr.  Arthur  T.  Neale,  Director  of  the  Delaware  College  Agri- 
cultural Experiment  Station  at  Newark,  Delaware,  and  Pro- 
fessor C.  L.  Penny.  Professor  of  Chemistry  at  the  Station,  I 
am  enabled  to  give  an  analysis  of  many  specimens  of  gluten 
flour  and  special  foods  purchased  in  the  general  market.  It 
is  only  necessary  to  go  into  such  work  to  see  how  utterly 

479 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

bereft  the  American  physician  is  of  proper  aids  in  fighting 
this  common  disease,  how  much  suffering  is  entailed  upon 
the  unfortunate  patients,  and  what  ignorance  or  rascahty,  or 
both,  are  rife  in  America  in  manufacturing  dietetic  products 
of  such  importance  and  general  use.  Take  a  grain  of  wheat 
and  cut  it  across.  In  the  centre  is  a  white  powder,  starch. 
This  is  a  carbohydrate,  carbon,  hydrogen,  and  oxygen.  From 
this  we  get  heat  and  fat,  but  no  power.  The  next  layer  is 
gluten,  a  proteid.  It  is  dark-colored,  and,  in  addition  to  the 
starch  elements,  contains  nitrogen.  Gluten  then  is  a  power- 
producer.  Then  we  get  the  phosphates  and  mineral  matters, 
which  help  to  make  the  bones  of  the  body,  etc.  The  outside 
is  the  bran,  which  is  flinty  and  indigestible,  and  makes  entire 
flour  a  bowel  irritant. 

Now,  white,  new-process  flour  has  little  gluten  and  com- 
paratively much  starch,  because  starch  is  white  and  gluten 
is  dark ;  and  the  market  demands  white  flour.  Thus  we  dis- 
card the  flesh-formers  in  our  white  flours,  and  keep  only  the 
fuel  and  fat-producers.  The  best  flour  for  eating  should  con- 
tain from  ten  to  fifteen  per  cent,  of  gluten,  or  more.  The 
patent  new-process  flours  contain  much  less,  and  much  of  the 
important  element  of  phosphorus  is  also  removed.  Gluten 
flour  for  diabetics  should  contain  not  less  than  seventy-five 
per  cent,  gluten.  The  books  tell  us  generally  that  the  gluten 
flour  special  products  of  Europe  are  much  lov/er  in  starch 
than  those  we  buy  in  America.  Probably  they  are,  although 
my  examinations  do  not  lead  me  to  get  much  encouragement 
in  England  and  Germany,  at  least.  Dr.  Frilden  gives  five 
examples  of  English  gluten  flour.  They  contained  7.6,  16.7, 
13.26,  68.8,  and  11.63  P^^  cent,  starch  and  sugar.  This  is 
comparatively  a  good  showing  as  such  flours  go.  Dr.  Kraus, 
Jr.,  of  Carlsbad,  found  only  five  specimens  to  contain  less 
than  thirty  per  cent,  carbohydrates.  Four  contained  between 
thirty  and  forty  per  cent.,  four  between  fifty  and  sixty  per 
cent.  This  is  a  bad  showing.  Wheat  flour  in  the  general 
market  contains  from  sixty  to  eighty  per  cent,  carbohydrates, 

480 


FORTY   YEARS    IN    THE   MEDICAL    PROFESSION 

accordingly  as  it  is  white  or  dark ;  the  greater  the  amount 
of  carbohydrates,  the  whiter  it  is. 

To  get  the  starch  out  of  flour  it  must  be  waslied,  when  the 
starch  runs  out  through  a  cloth  anrl  leaves  the  gluten  behind. 
Gluten  may  thus  be  obtained  starch  free.  It  is  very  difificult 
or  impossible  to  get  gluten  bread  absolutely  free  from  starch. 
Any  bread  under  twenty-five  per  cent,  starch  would  be  very 
encouraging  as  things  go  in  America,  or  even  in  Europe.  I 
should  at  present  hope  more  from  the  French  products.  Do 
not  turn  your  patients  loose  and  tell  them  to  buy  gluten  flour 
and  live  on  bread  made  from  it.  There  are  no  gluten  flours 
that  I  know  of  in  this  country.  They  are,  all  of  them  that  I 
have  examined,  frauds,  delusions,  and  snares.  Each  one  can 
make  better  himself.  Wash  the  starch  out  as  you  use  the 
flour  by  letting  a  stream  of  water  run  on  it  in  a  muslin  bag 
until  the  water  coming  through  ceases  to  be  milky.  Gluten 
is  like  glue:  by  dr3ang  it  becomes  brittle.  It  will  probably 
not  make  bread  without  at  least  a  little  starch  with  it. 

I  think  there  is  a  bright  business  opening  in  this  country 
for  a  firm  of  honest  men  to  go  into  the  business  of  manu- 
facturing and  selling  all  possible  special  dietetic  products  for 
invalids.  This  would  cover  diabetic  foods  and  drinks,  obesity 
foods  and  drinks,  dyspepsia  foods  and  drinks,  tissue-building 
foods  and  drinks,  fuel-producers,  flesh-formers,  and  all  such. 
I  know  of  no  such  firm  in  the  world  properly  organized  on  a 
basis  at  the  same  time  of  good  morals  and  honest  business 
principles.  Messrs.  G.  Van  Abbott  &  Sons,  No.  6,  Duke 
Street  Mansions,  Grosvenor  Square,  London,  W.,  appear 
from  their  advertisements  to  carry  a  large  stock  of  special 
foods.  They  have  kindly  sent  me  their  literature,  but  I  have 
no  samples  in  time  for  analysis.  They  make  diabetic  calf's- 
foot  jelly,  gluten  and  meat  biscuits,  carraway,  soya,  ginger, 
and  gluten  biscuits,  almond  loaves,  gluten  loaves,  soya  loaves, 
bran,  gluten,  and  almond  loaves,  gluten  slices,  etc.  They 
appear  to  get  up  biscuits  and  cakes  of  every  conceivable  com- 
position, suitable  apparently  for  all  invalids.  They  prepare 
31  481 


FORTY   YEARS    JN    THE   MEDICAL    PROFESSION 

diabetic  macaroni  and  vermicelli,  gluten  flour,  almond  flour, 
bran  flour,  diabetic  cocoa  and  chocolate,  etc.  This  is  just 
such  a  house  as  we  need  in  America,  honestly  and  thoroughly 
conducted. 

There  is  a  new  flour  out  for  diabetics,  called  the  Chicago 
sanitary  flour.  Bread  and  cake  made  from  it  are  said  to  be 
palatable.  It  should  be  used  moderately.  It  is  made  from 
edible  pine-nuts.  It  is  yellowish  in  color,  and  of  a  bland  taste. 
It  contains  no  starch  and  seven  per  cent,  of  cane-sugar.  Make 
bread  from  it  with  yeast,  and  nearly  all  of  this  sugar  goes  to 
alcohol,  leaving  less  than  one  per  cent,  sugar. 

The  soja  bean  is  a  new  product  from  which  to  make  a  dia- 
betic bread.  It  comes  to  us  from  Japan.  I  have  already 
spoken  of  it  as  a  vegetable,  dry  and  green.  It  contains  a 
very  little  starch,  four  to  six  per  cent.,  and  much  fat.  It  will 
prove  a  desirable  make-shift,  but  it  is  apt  to  get  rancid  from 
decomposition  of  its  fats.  "  Every  rose  has  its  thorn"  in 
substitutes  for  our  usual  bread-stuffs.  The  flour  from  the 
aleuronat-nut  is  also  a  late  introduction.  It  is  recommended 
by  Tyson,  a  good  authority.  I  find  it  very  expensive,  and  will 
speak  of  it  again. 

Let  me  speak  of  macaroni,  vermicelli,  spaghetti,  and  alpha- 
bet noodles.  These  are  usually  looked  upon  rather  as  gluten 
foods,  and  in  medical  books  I  have  seen  them  recommended 
as  such.  There  never  was  a  greater  mistake.  Every  one  I 
have  had  analyzed  has  shown  that  they  were  made  apparently 
from  wheat  flour  in  its  purity,  and  were  about  as  high  in 
carbohydrates  as  ordinary  wheat  flour.  We  ought  to  have 
gluten  macaroni,  vermicelli,  spaghetti,  and  alphabet  noodles. 
They  would  be  very  palatable  and  very  useful  food.  Van 
Abbott  advertises  them.  I  never  heard  of  any  in  America. 
The  sooner  we  get  them  the  better,  and  we  must  have  them. 
In  regard  to  macaroni  and  alphabet  noodles,  I  append  Dr. 
Neale's  letter.  The  analyses  were  made  by  Professor  C.  L. 
Penny.  The  macaroni  was  imported  Italian  macaroni,  and 
the  noodles  were  from  the  house  of  Olivier  Fils  et  Cie., 
Lyon,  France. 

482 


FORTY   YEARS   IN   THE  MEDICAL   PROFESSION 

Alphabet  Noodles.        Italian  Macaroni. 

Moi.sturc 9-33  9-^4 

Protein 1425  ^3-31 

Gluten,  dextrose,  and  other  sugars,  and 

similar  reducing  substances,  soluble 

in  cold  water 2.28  4.14 

Starch 70.38  68.56 

Ash,  fat,  etc.,  not  determined. 

"  In  Deutz's  work  on  the  adulteration  of  foods  a  statement  to  this  effect 
may  be  found :  Genuine  macaroni  is  made  from  wheat  gluten.  Imitation 
macaroni  is  made  from  wheat  flour.  Both  of  the  above  analyses,  as  far  as 
gluten  and  starch  contents  are  concerned,  might  easily  be  mistaken  for 
analyses  of  a  high  quality  of  wheat  flour.  If  Deutz  is  right,  neither  of  the 
above  samples  belongs  in  the  macaroni  class. 

"  Yours  truly, 

"  A.  T.  Ne.\le, 

"Director." 

From  a  great  number  of  samples  of  macaroni  products 
analyzed  from  the  exhibits  of  the  Chicago  Exposition  in  1893 
by  the  United  States  Government  experts,  only  one  sample 
showed  that  it  was  not  made  wholly  from  ordinary  wheat 
flour,  and  in  the  exception  there  was  only  a  little  common  salt 
and  some  oil  added.  So  much  for  macaroni  products,  both 
home-made  and  imported,  as  a  gluten  food.  A  letter  from  a 
high  official  of  the  Agricultural  Department,  Division  of 
Chemistry,  at  Washington,  says, — 

"  I  scarcely  think  you  will  be  able  to  find  any  noodles,  spa- 
ghetti, or  macaroni  in  our  markets  which  are  especially  rich 
in  gluten.  It  is  claimed  that  these  products  are  made  from 
flours  rich  in  gluten,  but  we  do  not  find  the  percentage  of  albu- 
minoids any  higher  than  one  would  expect  from  a  sample  of 
good  wdieat  flour.  In  fact,  we  have  reluctantly  come  to  the 
conclusion  that  the  so-called  gluten  flours  on  the  market  are 
not  by  any  means  to  be  trusted,  and  that  the  only  safe  way  for 
prescribing  gluten  flour  is  to  prescribe  a  known  brand  which 
is  sold  in  original  packages." 

I  may  add  to  this  that  the  original  packages  do  not  make 
better  exhibits  than  that  sold  in  bulk.  To  tell  macaroni  rich 
in  gluten,  examine  it  for  the  following  points :    \Mien  wet  it 

4S3 


FORTY   YEARS    IN    THE   MEDICAL    PROFESSION 

is  thrown  over  rods  to  dry.  If  rich  in  gluten  it  will  appear 
flattened  where  it  has  rested  on  the  rods.  If  it  is  not  rich  in 
gluten,  it  will  not  carry  its  own  weight,  and  cannot  be  dried 
on  rods.  Any  one  who  has  been  in  Florence,  particularly, 
can  remember  how  much  of  it  is  to  be  seen  hanging  out  to 
dry.  No  place  seems  too  foul  in  which  to  hang  macaroni  to 
dry.  The  more  gluten  there  is  in  macaroni  the  more  direct  is 
its  fracture,  the  larger  it  swells  when  cooked,  and  the  better 
it  holds  its  tubular  form.  If  we  are  paying  the  price  of  first- 
class  confectionery  for  a  mere  mixture  of  flour  and  water  for 
macaroni  and  such  products,  it  is  time  for  us  to  know  it  and 
to  endeavor  to  turn  the  attention  of  honest  manufacturers 
towards  the  proper  utilization  of  gluten. 

Soja-Bean  Meal. — This  bean  comes  to  us  from  Japan,  and 
is  said  to  contain  little  or  no  starch,  generally  less  than  one 
per  cent.  It  has  a  peculiar  oily  taste,  but  the  analysis  shows 
no  excess  of  fat.  Professor  Penny's  analysis  is  as  follows : 
Moisture,  8.14;  nitrogen,  14.54;  equivalent  to  protein  by 
calculation,  90.97.  Starch-like  bodies  capable  of  reducing 
Fehling's  solution,  trace  only.  A  letter  from  the  Theodore 
Metcalf  Drug  Company,  of  Boston,  says,  "  We  find  culti- 
vating the  bean  in  this  country  increases  the  amount  of  starch, 
and  we  are  awaiting  a  new  supply  from  Japan,  which  we  an- 
ticipate will  be  entirely  free  from  starch."  Here  is  a  copy  of 
a  letter  from  Dr.  Neale. 

"  The  statement  that  the  percentage  of  starch  in  soja  beans  is  dependent 
on  environment  interests  us  very  much.  A  reasonable  doubt  exists  as  to 
the  presence  of  starch,  strictly  speaking,  in  this  bean.  Years  ago  attention 
was  directed  to  this  plant  by  a  display  of  seed  made  by  Japan  at  the  Paris 
Exposition.  At  that  time  claims  w^ere  made  in  the  Halle  Laboratory  that 
no  starch  grains  could  be  detected  in  soja-bean  meal.  I  held  an  assistant's 
position  among  the  chemists  of  that  station  when  this  test  was  made,  and 
my  recollections  of  the  interest  aroused  then  are  now  reasonably  strong. 
Last  month  Professor  Chester,  of  this  station,  attempted  to  detect  starch 
in  a  bean  taken  from  the  package  sent  later  to  you.  He  reported  his  ina- 
bility to  obtain  a  positive  result,  quantitatively,  by  the  usual  microscopic 
and  chemical  (iodine)  test.  By  these  tests  the  absence  of  starch  was  indi- 
cated. The  ten  per  cent,  of  starch  reported  by  analysis  of  this  bean  means 
starch-like  bodies  capable  of  transformation  into  certain  sugars.     An  as- 


FORTY    YICARS    IN    TIIIi:   MliDICAL    I'KOFESSION 

sumption  exists  that  any  carbohydrate  may  be  deleterious  to  a  diabetic. 
Tlic  package  of  beans  sent  to  you  represents  a  crop  grown  on  the  college 
grounds.  The  seed  came  to  Newark  from  Kansas.  The  Kansas  supply 
was  brought  to  this  country  from  Japan  by  a  member  of  the  Kansas 
Experiment  Station  staff.  I  will  follow  this  matter  of  environment  by 
comparative  analyses  of  foreign  and  domestic  crops,  if  Mr.  Metcalf  will 
guarantee  the  origin  of  his  supply.  If,  however,  the  slightest  question 
arises  as  to  the  source  of  that  supply,  a  request  to  the  Honorable  Sec- 
retary of  Agriculture  will  doubtless  result  in  an  importation  through  con- 
sular channels  of  a  quantity  large  enough  for  this  study. 

"  Yours  truly, 

"Arthur  T.  Neale, 

"  Director." 

I  find  soja-bean  meal  to  make  a  fair  cake,  which  helps  out 
in  diet.  The  meal  must  be  kept  well  sealed,  or  it  turns  rancid 
from  a  transformation  of  its  fat.  Eaten  dried  as  a  vegetable, 
it  serves  a  purpose  in  diet,  but  patients  cannot  eat  them  every 
day  for  any  considerable  time.  I  have  not  had  the  opportu- 
nity of  testing  them  as  a  green  vegetable,  but,  as  I  have  said 
before,  I  have  great  hopes  of  their  use  in  this  direction. 

Soja-Mcal  Muffins  (Metcalf). — Take  of  cream,  one  cup; 
eggs,  two,  entire;  baking-powder,  one  teaspoonful;  salt  to 
taste;  soja-bean  meal,  enough  to  make  a  batter  not  too  thick. 
Make  into  eight  cakes. 

Soja  and  Gluten  Gems  (receipt  of  a  patient). — One  cup 
gluten  flour,  two  eggs,  one  cup  of  cream,  one  teaspoonful 
baking-powder,  enough  soja-bean  meal  to  make  a  stiff  batter, 
half-teaspoonful  extract  of  lemon.  This  does  away  with  the 
oily  taste  of  the  bean.  Bake  in  gem  pans.  With  a  high-grade 
gluten  flour  this  makes  a  good  bread. 

Van  Abbott,  of  London,  makes  a  soja  biscuit  flavored  with 
carraway,  which  is  palatable  now  and  then.  They  also  make 
a  soja  and  almond  biscuit.  These  are  useful  and  palatable. 
Almonds  save  albumin,  and  so  do  the  fats  in  the  soja  bean. 
Van  Abbott  also  makes  a  soja-bean  bread.  These  soja  prod- 
ucts do  not  keep  for  transportation  unless  hermetically  sealed, 
which  is  readily  done. 

Professor  John  Attfield's  analysis  of  a  soja-bean  flour  in 
1890  was  as  follows  : 

48s 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

Nitrogenous  or  flesh-forming  material 41.24 

Fatty  or  warmth-giving  material 13.70 

Other    warmth-giving    substances    (cellulose,    starch, 

sugar)      30.35 

Phosphate  or  bone-forming  material 4.81 

Other   natural   mineral   matter .52 

Moisture 9.38 

Total 100.00 


Probably  most  of  the  carbohydrates  here  were  in  the  form 
of  cellulose,  which  would  not  affect  it  as  diabetic  food  to  any 
great  extent. 

Dr.  James  Tyson  and  other  authorities  recommend  the 
flour  made  from  the  aleuronat-nut.  I  have  used  it,  and  find 
it  very  expensive  and  not  free  from  other  objections.  My 
supply  came  from  a  retail  druggist  in  Philadelphia. 

The  following  analyses  have  been  made  by  Professor 
Penny : 

Aleuronat  flour :  Moisture,  6.  i ;  nitrogen,  equivalent  to 
protein  by  calculation,  31.81  (nitrogen,  5.73)  ;  starch-like 
bodies  capable  of  reducing  Fehling's  solution,  22.64. 

Sample  of  gluten  flour  from  a  factory  in  New  York  State, 
marked  ''Special  Diabetic  Flour:"  Protein,  15.50;  soluble 
sugars,  dextrose,  etc.,  2.20;  starch,  59.87;  water,  fat,  ash, 
etc.,  to  balance.  In  round  numbers  wheat  flour  may  have 
seventy  per  cent,  of  starch-like  bodies.  Wheat  bran  in  com- 
position closely  resembles  this  sample  of  gluten  flour. 

Sample  of  gluten  grits  from  the  same  factory.  This  is 
put  forth  as  a  thoroughly  reliable,  palatable,  and  satisfactory 
breakfast  dish  and  dessert  cereal  for  diabetics  and  those  suf- 
fering from  obesity,  etc.:  Protein,  11.56;  starch,  73.85; 
soluble  reducing  bodies,  dextrose  (  ?),  .42. 

It  is  a  very  serious  business  to  be  putting  such  trash  as  this 
on  the  market  as  a  suitable  food  for  invalids  in  certain  dis- 
eases. How  many  are  using  them  with  a  false  idea  of  their 
own  security  no  one  knows,  and  how  many  physicians  are 
innocently  recommending  them  will  never  be  determined. 
This  showing,  I  trust,  will  put  all  on  guard,  and  end  in  a 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

possibility  sooner  or  later  of  obtainini^  a  proper  food-supply 
for  these  unfortunate  invalids. 

Gluten  (lour  from  a  Jioston  firm:  Moisture,  10.90;  gluten, 
15.69;  starch,  61.58;  dextrose,  1.53.  This  is  a  little  worse, 
if  anything-,  than  the  New  York  State  sample. 

Sample  of  white  wheat  gluten  from  a  Health  Food  Com- 
pany in  Philadelphia :  Moisture,  11. 17;  gluten,  16.31;  starch, 
59.17;  dextrose,  2.29.  This  is  another  specimen  unfitted  as 
diabetic  food,  although  it  is  possibly  a  little  better  than  the 
others. 

Wheat  gluten  from  a  Michigan  Sanitarium  Health  Food 
Company:  Moisture,  7.54;  gluten,  18.28;  starch,  67.20; 
dextrose,  1.53.  I  expected  a  better  showing  from  this  source, 
but  the  analysis  speaks  for  itself.  Professor  Tyson  has 
recommended  the  gluten  flour  of  this  firm  as  among  the 
best  to  be  found,  and  such  a  recommendation  must  have 
given  it  a  large  sale. 

Granon  flakes  from  the  same  company:  Moisture,  9.77; 
gluten,  10.50;   starch,  69.52;   dextrose,  .76. 

Gluten  biscuit  from  the  same  company:  Moisture,  11.62; 
gluten,  25.19;  starch,  60.12;  dextrose,  1.40.  The  analysis 
tells  the  story  here. 

Nut  gluten  biscuits  from  the  same  company :  Protein,  38*; 
starch,  15.9;  soluble  reducing  bodies,  dextrose,  1.17.  This 
is  a  creditable  showing,  and  these  biscuits  are  among  the  best 
of  the  bread-foods  I  have  found  in  the  general  market  for 
the  diabetic  or  the  obese.  They  are  evidently  shortened  with 
nut  oil  and  have  a  taste  like  rich  puff  paste.  This  company 
makes  a  forty  per  cent,  gluten  biscuit  which  I  did  not  have 
analyzed.  They  are  very  palatable  and  taste  like  the  egg  bis- 
cuits of  the  grocery  shops.  Their  twenty  per  cent,  gluten 
wafers  were  not  analyzed.     They  taste  like  hardtack. 

If  you  can  get  a  proper  gluten  flour,  say,  with  not  over  ten 
to  fifteen  per  cent,  of  carbohydrates,  you  can  make  quite  pala- 
table bread  and  cakes,  but  starch  and  sugar  hunger  will  assert 
themselves  now  and  again.  If  stronger  bread  must  be  eaten 
at  intervals,  the  more  it  can  be  toasted  up  to  charring,  the 

487 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

better  it  will  be  for  the  diabetic  eating  it.  The  substitutes 
for  sugar  already  spoken  of  may  be  used,  and  thus  make 
quite  palatable  dishes,  even  porridges.  Bran  is  sometimes 
added  to  gluten  flour.     Do  not  use  too  much  of  this. 

To  make  bread  from  gluten  flour,  make  a  firm  paste  with 
warm  water.  Dissolve  one-quarter  to  one-half  of  a  com- 
pressed yeast-cake  in  a  little  cold  water.  Salt  to  taste.  Put 
the  dough  in  a  pan  powdered  with  gluten  flour.  Place  it  be- 
fore the  fire,  and  in  two  hours  it  should  be  raised.  Make  the 
dough  into  small  loaves  and  bake  it.  To  make  cake,  add  four 
entire  eggs  and  one-quarter  pound  of  butter,  and  sweeten 
with  glycerin  or  one  of  the  sugars  recommended, — saccharin, 
mannite,  or  diabetin.  Some  flavoring  may  be  added  if  pre- 
ferred. A  good  substitute  for  milk  may  be  made  by  a  fresh 
egg  beaten  up  thoroughly  and  a  modicum  of  sugar  of  milk 
added  to  it  with  a  little  water. 

Almond  flour  is  much  recommended  by  Pavy  as  a  food 
for  diabetics.  In  my  experience  patients  do  not  take  well 
to  it.  It  does  well  for  flavoring  porridge  and  cakes  made 
from  gluten  flour.  A  very  little  bran  added  to  porridge 
lightens  it,  acts  on  the  bowels,  and  does  not  do  serious  harm. 
Gluten  does  not  dissolve  until  it  enters  the  system,  and  should 
be  taken  in  a  state  of  suspension. 

It  is  estimated  that  the  American  people  alone  spend  ninety 
millions  of  dollars  annually  on  adulterated  foods.  There  are 
imitations  of  everything  good  or  useful  in  dietetics.  The 
better  things  are,  the  more  they  are  imitated  and  the  more 
they  are  adulterated.  You  can  make  bread  from  ground 
damaged  peas,  rice,  and  soapstone.  These  ingredients  have 
been  found  in  brands  of  wheat  flour,  and  the  scoundrels 
making  such  are  still  unhanged.  Peanut  oil  and  cotton-seed 
oil  are  both  sold  as  olive  oil.  The  deception  here  is  really 
more  in  the  name  than  in  the  quality,  but  the  fraud  is  no  less 
glaring.  Potato  starch  is  used  to  adulterate  sago,  and  glu- 
cose, flour,  and  clay  can  make  a  sugar  to  be  sold  as  cane- 
sugar.  Potatoes,  white  and  sweet,  chicory,  peas,  beans,  and 
acorns   are  manipulated   and   sold  as  pure  coffee,   and   the 


FORTY    YK.'VRS    IN    THE    MKDICAL    PROFESSION 

coffee-bean  itself  is  now  imitated,  no  coffee  whatever  being 
used.  Butter  has  been  successfully  imitated  by  oleomarga- 
rine and  sold  as  butter.  Here  is  the  fraud.  As  oleomarga- 
rine, people  know  what  they  are  getting.  Filled  cheese  is 
very  common,  and  thus  skim-milk  and  lard,  or  rather  fats, 
are  sold  as  full  cheese.  As  to  spices,  no  man  knows  what 
they  contain.  Condemned  hardtack  is  a  favorite  adulterant. 
Sand,  bran,  sawdust,  cocoanut-shells,  corn-meal,  olive  seeds, 
and  all  sorts  of  earths  and  clays  are  used  as  adulterants.  Pure 
cider  vinegar  is  likely  to  be  dilute  sulphuric  acid  flavored  with 
any  sour  trash  available.  Chrome  yellow,  that  horrible  soul- 
consuming  poison,  is,  I  have  no  doubt,  still  used  to  give  a 
golden  egg  color  to  the  products  of  some  bakers.  Candy  is 
subject  to  all  kinds  of  adulterants,  and  the  only  end  to  it  is 
when  the  proper  ingredients  are  cheaper  than  the  injurious 
ones.  Honey  is  imitated  by  maple  sugar  and  glucose,  and 
the  very  combs  are  imitated  to  hold  it.  As  to  preserves, 
those  sold  in  the  shops  are  mostly  horrors.  Glucose,  gelatin, 
cochineal,  with  flavoring  extracts  from  the  coal-tar  deriva- 
tives, compose  the  most  of  them,  and  whatever  Providence 
may  vouchsafe  to  us  in  the  way  of  fruits,  whether  the  har- 
vest be  great  or  small,  these  frauds  are  always  obtainable 
by  ignorant,  credulous  purchasers,  the  victims  of  conspiracy 
most  injurious  and  most  foul.  So  it  is  in  the  furnishing  of 
special  dietetic  foods  for  the  diabetic,  fraud  keeps  pace  with 
rapacity;  and  as  we  progress  in  the  evolution  of  knowledge 
to  eradicate  or  check  these  scourges  to  mankind,  the  evolu- 
tion of  greed  and  deception  keeps  pace  with  us,  and  the 
sorry  victims  are  sacrificed  on  the  altar  of  "  man's  inhuman- 
ity to  man." 

I  take  great  pleasure  in  introducing  here  a  poem  which  has 
come  to  me  merely  as  a  newspaper  clipping.  I  have  en- 
deavored to  trace  its  authorship  and  its  history,  but  have 
been  able  to  find  nothing  reliable  pertaining  to  either,  more 
than  the  few  lines  of  explanation  published  with  it.  I  applied 
to  both  Mr.  Spofford  and  J\Ir.  David  Hutcheson.  of  the  Con- 

489 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

gressional  Library  at  Washington,  but  neither  could  give  me 
any  trace  of  the  composition  or  of  its  writer.  It  has  so  much 
merit,  and  exhibits  such  deep  conceptions  of  human  thought 
and  sentiment,  that  I  deem  it  worthy  of  much  more  careful 
preservation  than  the  mere  ephemeral  existence  this  publica- 
tion may  give  it. 

"  More  or  less  interest  always  attaches  to  anonymous  poetic 
productions,  even  when  the  quality  is  not  very  high,  but  the 
following  lines,  found  in  1807  near  one  of  the  skeletons  in 
the  Royal  College  of  Surgeons,  London,  aroused  unusual 
curiosity,  not  only  on  account  of  the  unique  theme,  but  prin- 
cipally because  of  the  poetic  perfection  displayed.  Great 
efforts  were  made  to  ascertain  the  identity  of  the  writer,  and 
at  one  time  a  reward  of  one  hundred  guineas  was  offered  for 
the  discovery  of  the  author,  but  he  has  ever  remained  a 
mystery. 

(I) 

"  Behold  this  ruin !     'Twas  a  skull 
Once  of  ethereal  spirit  full. 
This  narrow  cell  was  Life's  retreat, 
This  space  was  Thought's  mysterious  seat. 
What  beauteous  visions  filled  this  spot. 
What  dreams  of  pleasure,  long  forgot ! 
Nor  hope,  nor  love,  nor  joy,  nor  fear 
Have  left  one  trace  of  record  here. 


(2) 

Beneath  this  mouldering  canopy 
Once  shone  the  bright  and  busy  eye ; 
But — start  not  at  the  dismal  void — 
If  social  love  that  eye  employed ; 
If  with  no  lawless  fire  it  gleamed, 
But  through  the  dews  of  kindness  beamed, 
That  eye  shall  be  forever  bright 
When -stars  and  suns  are  sunk  in  night. 
490 


FORTY    YEARS    IN    THE    MEDICAL    PROFESSION 

(3) 
"  Within  this  liollow  cavern  Inmg 
The  ready,  swift,  and  tuneful  tongue: 
If  Falsehood's  honey  it  disdained, 
And  where  it  could  not  praise  was  chained; 
If  bold  in  Virtue's  cause  it  spoke, 
Yet  gentle  concord  never  broke. 
This  silent  tongue  shall  plead  for  thee 
When  time  unveils  eternity. 

(4) 
"  Say,  did  these  fingers  delve  the  mine? 
Or  with  its  envied  rubies  shine? 
To  hew  the  rock  or  wear  the  gem 
Can  little  now  avail  to  them  ; 
But  if  the  page  of  truth  they  sought, 
Or  comfort  to  the  mourner  brought. 
These  hands  a  richer  meed  shall  claim 
Than  all  that  wait  on  wealth  or  fame. 

(5) 
"  Avails  it  whether  bare  or  shod 
These  feet  the  paths  of  duty  trod  ? 
If  from  the  bowers  of  ease  they  fled, 
To  seek  Affliction's  humble  shed; 
If  Grandeur's  guilty  bribe  they  spurned. 
And  home  to  Virtue's  cot  returned. 
These  feet  with  angel's  wings  shall  vie, 
And  tread  the  palace  of  the  sky." 


491 


INDEX. 


Abortion  and  miscarriage,  1 06. 

Acapulco,  14. 

Agnew,  D.  Hayes,  M.D.,  41. 

Alcohol,  269. 

Alcohol  in  diabetes  mellitus,  458. 

Alcohol,  retarding  digestion,  300. 

Alcohol,  when  to  give,  301. 

Alcoholic  drinks,  consumption  of,  298. 

Aleuronat  flom',  486. 

Almond  flour,  488. 

Almonds,  371. 

Alphabet  noodles,  482. 

American  wines,  291. 

Anabolism,  424. 

Analyses   of  diabetic   flours,   etc.,  485- 

487. 
Appendicits,  117. 
Apple  and  Pear,  Alligator,  339. 
Apples,  319. 
Argonauts,  31. 
Ardiritis  deformans,  422. 
Arthritis  defonnans  multiple,  423. 
Asepsis  and  Antisepsis,  99. 
Atlee,  JohnL.,  M.D.,  57. 
AUee,  Walter  F.,  M.D.,  57. 
Atlee,  Washington  L.,  M.D.,  57. 
Atropia  in  tlie  eye,  113. 
Atwater,  Professor  O.  W.,  424. 
Auscultation  and  percussion,  131. 
Austraha,  fruit  in,  315. 
Auto-intoxication  in  disease,  192. 

B. 

Bacillus  of  Eberdi,  150. 
Bacillus  of  tetanus,  168. 
Bacillus  tuberculosis,  379. 


Banana,  340. 

Banting  and  Ebstein,  223. 

Barr,  M.  W.,  on  the  feeble-minded,  177. 

Barton,  John  Rhea,  55. 

Bartram,  John,  314. 

Bean,  soja,  482. 

Bee,  honey,  sting  of,  and  immunity,  169. 

Beer,  ale,  porter,  274,  275. 

Betel  nut,  373. 

Bicycle,  143. 

Blackberry,  353. 

Bloat,  cause  of,  436. 

Blood,  etc.,  141. 

Brandy,  272. 

Brandy,  American,  295. 

Braun,  Karl,  85. 

Bread  for  diabetics,  479. 

Breads,  228. 

Bromelin,  308. 

Burgundy  and  clarets,  284. 

Burnett,  C.  H.,  M.D.,  58. 

Buttermilk,  241. 


California  clarets,  etc.,  293. 
California  hocks,  293. 
Cahfomia  sweet  wines,  293. 
California,  wine  product  of,  292. 
Camac,  C.  N.  B.,  M.D.,  155. 
Camac,  Wm.,  iSI.  D.,  60. 
Canned  foods,  212. 
Cantaloupes,  346. 
Carlsbad,  199,  444. 
Carson,  Joseph.  M.D.,  38. 
Champagne,  287. 
Champagne,  American,  295. 
Chern.-,  351. 


493 


INDEX 


Chestnuts,  368. 

Chicago  sanitary  flour,  482. 

Chilean  nut,  373. 

Chocolate,  215. 

Clarets,  Virginia  and  New  Jersey,  294. 

Climate  of  San  Francisco,  23. 

Clinical  Thermometer,  124. 

Cocoa,  215. 

Cocoa-nut,  339. 

Coffee,  214. 

Coma,  diabetic,  461,  463. 

Composition  of  food,  209. 

Consumption,  acute,  388. 

Consumption,  cure  of,  381,  395. 

Convulsions,  ursemic,  440. 

Cooper,  E.  S.,  M.D.,  22. 

Cottage  cheese,  241. 

Country  doctor,  90. 

Cranbeny,  351. 

Cream,  Devonshire,  240. 

Cream  nuts,  373. 

Currants,  351. 

D. 

Da  Costa,  J.  M.,  M.D.,  58. 

Dana,  R.  H.,  Jr.,  19. 

Date  plum,  337. 

Deaf  and  dumb,  183. 

Death  struggle,  196. 

Defective  classes,  186. 

Dewberry,  353. 

Diabetes  and  Tuberculosis,  447,  465. 

Diabetes  mellitus,  446. 

Diabetes  mellitus,  cause  of,  451. 

Diabetes  mellitus,  cure  of,  459. 

Diabetes  mellitus,  diagnosis  of,  455. 

Diabetes  mellitus,  diet  in,  473. 

Diabetes  mellitus,  treatment  of,  462. 

Diabetes  mellitus,  true,  468. 

Diabetes,  thyroid  extract  in,  463. 

Diabetic  foods,  manufacture  of,  481. 

Diazo  reaction,  150. 

Diet,  197. 

Diet  and  women,  226. 

Diet  in  middle  age,  248. 

Diet  in  old  age,  249. 

Diet  table,  224. 

Dietary  studies,  216. 


Diets,  improper,  226. 

Digestion,  time  required  for,  etc. ,  235 . 

Digitalis,  128. 

Division  of  foods,  200. 

Doyle,  A.  Conan,  91. 

Drinks  in  diabetes,  473. 

Ductless  glands,  137. 

Duels,  22. 

Durian,  337. 

E. 

Eggs,  all  about  them,  206. 
Electricity,  143. 
English  walnut,  375. 
Ether  and  chloroform,  82. 
Ether  and  chloroform   in   pelvic  opera- 
tions, 83. 
Ether  and  oxygen,  84. 
Examination  of  urine,  145. 


F. 

Figs,  339. 

Filberts,  371. 

Flour,  gluten,  479,  486. 

Food,  adulterations  of,  488,  489. 

Food  fads,  25 1 . 

Food  necessary  for  a  man  in  twenty-four 

hours,  220. 
Food,  uses  of,  425. 
Foods,  composition  of,  203. 
Foods,  infant,  247,  258. 
Fractures  and  compound  fractures,  121. 
Frerichs,  85. 
Fruit-juices,  312. 
Fruit,  when  to  eat,  307. 
Fruits  and  nuts  as  diet,  304. 
Fruits  and  vegetables,  definitions  of,  309. 
Fruits,  composition  of,  307. 
Fruits,  decay  of,  356. 
Fruits,  dried,  312. 
Fruits,  uses  of,  in  the  animal  economy, 

3"- 

G. 

Gerhard,  W.  W.,  M.D.,  55. 
Germain  S6e  diet,  226. 
Germs,  soja  and  gluten,  485. 


494 


INDEX 


Gihicr,   I'aiil,    M.l).,    iiiid    tuberculosis, 

410. 
Gin,  273. 
Glaucoma,  113. 
Gluten  biscuits,  4S7. 
Gluten  bread,  488. 
Glycogenic  matter,  447. 
Glycosuria,  temporary,  450. 
Glycosuria,  tnie,  468. 
Goddard,  Paul  Beck,  M.l).,  55. 
Gonococcus  of  Neisser,  108. 
Gooseberries,  350. 
Gout,  423. 

Gout,  a  neurosis,  429. 
Gout  and  diabetes  mellitus,  454,  460. 
Gout,  nature  and  causes  of,  426. 
Gout,  rheumatic,  422. 
Gout,  treatment  of,  430. 
Grape-fmit,  344. 
Grape-juice,  296. 
Grapes,  331. 
Grits,  gluten,  486. 
Gross,  Samuel  David,  49. 
Guarana,  374. 
Guava,  339. 
Gynecology,  115. 

H. 

Haemoglobin,  142. 

Hcemostat,  122. 

Haig,  Alexander,  M.D.,  427. 

Haw,  350. 

Hay- fever,  414. 

Hays,  Isaac,  M.D.,  58. 

Headache,  gouty,  440. 

Heart,  intermitting  and  in'egular,  435. 

Heart  remedies,  12S. 

Hemoixhage   from   genitals  in    females, 

107. 
Hernia,  initaut  injections  in,  119. 
Hip-joint  amputations,  20,  51. 
Hodge,  Hugh  L.,  M.D.,  ^S- 
Hospital,  United  States  Marine,  14. 
Hunger,  starch  and  sugar,  4S7. 
Hunt,  Wm.,  M.D.,  40. 
Hydrophobia,  77. 
Hypnotism,  186. 
H)-podeiTnic  Syiinge,  124. 


I. 

Immunity,  93. 

Infants  in  Hlockley,  224. 

Insane  and  diabetes  mellitus,  455. 

Intestinal  toxamia,  195. 

Intubation,  119. 

Iron,  139. 


Jackson,  Samuel,  M.D.,  37. 
Japanese  emhia.s.sy,  the  first,  19. 
Japanese  Tommy,  19. 
Jefferson  Medical  College,  48. 
Jiggers,  17. 
Jordan's  tables,  305. 

K. 

Kalagua,  412. 
Katabolism,  424. 
Kidney,  movable,  158. 
Koch,  77. 

Koch's  law,  92,  379. 
Kola  nut,  374. 
Koumiss,  205. 

L. 

Lamballe,  Jobert  de,  70. 
Lane,  L.  C,  M.D.,  22. 
Laryngeal  paralysis  after  typhoid  fever, 

153- 
Lawyer,  sea,  16. 
Lead  poisoning,  212. 
Leaves,  why  they  turn  color,  317. 
Leguminous  plants  and  nitrogen,  161. 
Leidy,  Joseph,  M.D.,  39. 
Lemons,  345. 

Levis,  R.  J.,  M.D.,  34,  63. 
Liquid  air,  127. 
Lister,  Lord,  97. 
Logan  belt)-,  350. 
Lupus  \"ulgaris,  392. 
L)-ing-in  women,  105. 

M. 
McAllister  family,  250. 
McAllister,  Ward,  250. 
Macaroni,  482. 


495 


INDEX 


Maclaren,  Ian,  91. 

Madeira  and  Ward  McAllister,  282. 

Maderia  wine,  282. 

Malt  extracts,  275. 

Malthusian  theor}',  163. 

Mango,  337. 

Mangosteen,  337. 

Manzanillo,  14. 

Maragliano's  serum,  385. 

Maxwell,  R.  T.,  M.D.,  21. 

Mayer,  Dr.,  theory  of  diabetes  mellitus, 

452. 
Medical  supervision  of  families,  114. 
Meigs,  Charles  D.,  M.D.,  82. 
Meigs,  John  F.,  M.D.,  56. 
Metabolism,  424. 
Milk  and  infants,  245. 
Milk  as  food,  236,  259-261. 
Milk,  condensed,  240. 
Milk,  dehvery  of,  etc. ,  263. 
Milk,  evaporated,  240. 
Milk,  impure,  263. 
Milk,  Pasteurized,  239. 
Milk,  Pearson' s  rules,  266. 
Milk,  sterilized,  238. 
Milk  supply  and  police  power,  241. 
Milk,  tests  of,  264. 
Milk,  Walker  Gordon,  241. 
Mistakes  in  Diagnosis,  146. 
Mitchell,  S.  Weir,  M.D.,  45,  226. 
Morels,  363. 

Morton,  Thomas  G.,  M.D.,  56. 
Moselle  wines,  286. 
Movement  cures,  185. 
Muffins,  soja,  485. 
Mulberry,  346. 

Murphy  and  tuberculosis,  394. 
Murphy' s  button,  116. 
Mushrooms,  357. 
Mushrooms,  rules  for  gathering,  365. 

N. 

Napoleon  III.,  71. 

Nash,  43. 

Neale,  Dr.  A.  T.,  410. 

Nelaton,  70. 

Newcastle,  Delaware,  87. 

Nitrogen  in  diet,  203. 


Nitrous  oxide  gas,  137. 
Noodles,  alphabet,  482. 
Normal  salt  solution,  155. 
Normandy,  69. 
Nuclein,  420. 
Nuts,  367. 


Oakland,  24. 

Obesity  and  diabetes  mellitus,  454, 

Oertels  diet,  225. 

Olives,  345. 

Operations  in  malignant  disease,  108. 

Oranges,  343. 

Origin  of  life,  98. 


Pancoast,  Joseph,  M.D.,  48. 

Papaw,  308,  338. 

Park,  Golden  Gate,  28. 

Partridge  berry,  348. 

Pasteur,  77. 

Port  wine,  282. 

Peach,  Doctor  Black,  326. 

Peaches,  324. 

Peaches  for  diabetics,  327. 

Peanuts,  371. 

Pears,  327. 

Pecans,  372. 

Penny,  Professor  C.  L.,  415. 

Penrose,  R.  A.  F.,  M.D.,  44,  63. 

Pepper,  William,  Jr.,  36. 

Pepper,  William,  Sr.,  35. 

Pessary,  Goddard's,  34. 

Pfeiffer,  bacillus,  387. 

Pharmacy  and   chemistry,  advances   in, 

134- 
Philadelphia  clinics,  51. 
Philadelphia  Hospital,  Blockley,  61. 
Phloridzin,  451. 
Pichi,  442. 
Pine-apple,  341. 
Piperazin,  140. 
Pistachio  nut,  373. 
Plasmodium  malarias,  147. 
Plums,  334. 

Pneumonia,  chronic  interstitial,  383. 
Poem,  anonymous,  489. 


496 


INDEX 


I'oke  berry,  350. 
Pomegranate,  338. 
Preserves  and  canned  fruits,  313. 
Preventive  medicine,  104. 
Princeton  Collej^e,  ;i;i. 
Profession  in  Delaware,  8g. 
Profession  in  Kngiand,  76. 
Profession  in  (lennany,  85. 
Profession  in  Paris,  74- 
Pranellos,  336. 
Prunes,  336. 
Ptomaines,  188. 
Piiff-halis,  363. 


Queensland  nut,  373. 

Quince,  352. 

Quiz  classes  in  Philadelphia,  42. 

R. 

Rabies,  78. 

Rabies  mephitica,  78. 

Rheumatism,  418, 

Rheumatism,  pathogenic  germ  of,  419. 

Rhine  wines,  2S6. 

Ricord,  72. 

Rontgen  rays,  123. 

Rum,  273. 

S. 

Sailors,  16. 

San  Francisco,  13,  21,  24. 
Sauteme,  285. 
Schweninger  diet,  225. 
Scurvy,  adult,  17. 
Scurvy,  infantile,  252. 
Serum  therapy,  137,  384. 
Serum  treatment  in  lower  animals,  171. 
Shellbark,  372. 
Sheny  wine,  281. 
Shipwrecked,  67. 
Simpson,  76,  81. 
Sims,  J-  Marion,  73. 
Skoda,  85. 

Smith,  Francis  Gumey,  M.D.,  37. 
Smith,  H.  H.,  M.D.,  38. 
Souari  nut,  376. 
Special  diets,  222. 
32 


Slelwag(jn,  II.  W.,  M.l;.,  60. 

Strawberry,  354. 

Strawbridge,  (leorgc,  M.D.,  58. 

Sugar,  substitutes  for,  472. 

Sugar,  tests  for,  456. 

Syme,  James,  M.lJ.,  76,  81. 

Sy])hilis,  ill. 

T. 
Tamarinds,  337. 
Tea,  214. 

Tetanus  and  treatment  of,  166. 
Thermotherapy,  120. 
Thyroid  extract  in  gout,  443. 
Toast,  230. 
Tracheotomy,  1 1 9. 
Travers,  William  R.,  447. 
Trousseau,  73- 
Truffles,  363. 
Tubercle,  378. 
Tuberculin  A,  384. 
Tuberculin  O,  385. 
Tuberculin  R,  385.  • 
Tuberculin  in  diagnosis,  388. 
Tuberculocidin,  383. 
Tuberculosis,  377. 
Tuberculosis  and  anthrax,  410. 
Tuberculosis,  climates  for,  404. 
Tuberculosis,  inhalations  in,  41 1. 
Tuberculosis  in  lower  animals,  390. 
Tuberculosis,  prevention  of,  389. 
Tuberculosis,  pulmonary,  380. 
Tuberculosis,  serums  for,  408. 
Tuberculosis,  specifics  for,  410. 
Tuberculosis,  treatment  of,  396. 
Tjnidall,  76. 
Typhoid  fever,  150. 

Typhoid  fever,  second  time  in  same  in- 
dividual, 154. 
Typhoid  septicaemia,  155- 
Tj'phus  fever,  64. 
Tyson,  Professor  James,  441. 

U. 
Univei-sity  of  Pennsylvania,  32. 
Uraemia,  193. 
Urea  and  oxidation,  201. 
Uric  acid,  source  of,  419. 


497 


INDEX 


V. 

Van  Abbott  &  Sons,  481. 

Velpeau,  69. 

Virchow,  385. 

Vivisection,  133. 

Von  Grafe,  85. 

Von  Langenbeck,  85. 

W. 

Wall  disease,  160. 
Walnut,  black,  374. 
W'alnut,  Japan,  375- 


\N'ater  as  a  remedy,  201. 
Watennelon,  346. 
Wharton,  H.  R.,  M.D.,  59. 
Whey,  241. 
Whiskey,  272. 
Widal  test,  155. 
Winebeny,  350. 
Wine  residues,  297. 
Wine  taster,  280. 
Wines,  276. 

Wines,  adulterated,  296. 
Wood,  Professor  H.  C,  386. 
Woods,  D.  F.,  M.D.,  58. 


THE   END. 


498 


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